Improving survival from sudden cardiac arrest: the "chain of survival" concept. A statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association

App-based learning as an alternative for instructors in teaching basic life support to school children: a randomized control trial

Background: The importance of early cardiopulmonary resuscitation (CPR) during an out-of-hospital cardiac arrest (OHCA) cannot be emphasized enough and has a major impact on survival. Unfortunately, CPR education in schools is often inadequate or non-existing due to lack of educators and financial resources. The introduction of application-based teaching could facilitate education as no instructor is needed. The aim of present study is to compare app-based self-teaching (intervention group) with a traditional instructor-led course (control group). This trial is in line with the endorsement of training school children by the World Health Organization (WHO). Methods: This randomized controlled trial contains 165 participants between 16 and 18 years. The control group followed an instructor-led course, while the intervention group used a tablet application to complete a self-education course.Both groups were taught in separated classes during 40 min and used manikins and automated external defibrillator (AED) trainer kits. Before and after training, both groups were evaluated in a practical test to examine their skills (an overall score and sub-scores on different sections were obtained, following ERC 2015 guidelines). Results: No significant difference (p = 0.304) in overall teaching effectiveness was found between both groups. Although, in a sub-analysis, we found significantly better results for the instructor group for checking airway (p = 0.018), asking for an AED (p < 0.01) and shocking the patient (p = 0.002). Conclusions: App-based teaching can be a valuable alternative for classic instructor-based education. Yet new apps have to be evaluated before being implemented in CPR education.

A local neighborhood volunteer network improves response times for simulated cardiac arrest

AIM

Each minute is crucial in the treatment of out-of-hospital cardiac arrest (CA). Immediate chest compressions and early defibrillation are keys to good outcomes. We hypothesized that a coordinated effort of alerting trained local neighborhood volunteers (vols) simultaneously with 911 activation of professional EMS providers would result in substantial decreases in call-to-arrival times, leading to earlier CPR and defibrillation.

METHODS

We developed a program of simultaneously alerting CPR- and AED-trained neighborhood vols and the local EMS system for CA events in a retirement residential neighborhood in Southern Arizona, encompassing approximately 440 homes. The closest EMS station is 3.3 miles from this neighborhood. Within this neighborhood, 15 vols and the closest EMS station were involved in multiple days of mock CA notifications and responses.

RESULTS

The two groups differed significantly in distance to the mock CA event and in response times. The volunteers averaged 0.3 ± 0.2 miles from the mock CA incidences while the closest EMS station averaged 3.4 ± 0.1 miles away (p < 0.0001). Response times (time from call to arrival) also differed. Two volunteers, one bringing an AED, averaged 1 min 38 s ± 53 s in Phase 1, while it took the EMS service an average of 7 min 20 s ± 1 min 13 s to arrive on scene; p < 0.0001.

CONCLUSION

Local neighborhood volunteers were geographically closer and arrived significantly sooner at the mock CA scene than did the EMS service. The approximate time savings from call to arrival with the volunteers was 4-6 min.

Quantitative EEG Metrics Differ Between Outcome Groups and Change Over the First 72 h in Comatose Cardiac Arrest Patients

BACKGROUND

Forty to sixty-six percent of patients resuscitated from cardiac arrest remain comatose, and historic outcome predictors are unreliable. Quantitative spectral analysis of continuous electroencephalography (cEEG) may differ between patients with good and poor outcomes.

METHODS

Consecutive patients with post-cardiac arrest hypoxic-ischemic coma undergoing cEEG were enrolled. Spectral analysis was conducted on artifact-free contiguous 5-min cEEG epochs from each hour. Whole band (1-30 Hz), delta (δ, 1-4 Hz), theta (θ, 4-8 Hz), alpha (α, 8-13 Hz), beta (β, 13-30 Hz), α/δ power ratio, percent suppression, and variability were calculated and correlated with outcome. Graphical patterns of quantitative EEG (qEEG) were described and categorized as correlating with outcome. Clinical outcome was dichotomized, with good neurologic outcome being consciousness recovery.

RESULTS

Ten subjects with a mean age = 50 yrs (range = 18-65) were analyzed. There were significant differences in total power (3.50 [3.30-4.06] vs. 0.68 [0.52-1.02], p = 0.01), alpha power (1.39 [0.66-1.79] vs 0.27 [0.17-0.48], p < 0.05), delta power (2.78 [2.21-3.01] vs 0.55 [0.38-0.83], p = 0.01), percent suppression (0.66 [0.02-2.42] vs 73.4 [48.0-97.5], p = 0.01), and multiple measures of variability between good and poor outcome patients (all values median [IQR], good vs. poor). qEEG patterns with high or increasing power or large power variability were associated with good outcome (n = 6). Patterns with consistently low or decreasing power or minimal power variability were associated with poor outcome (n = 4).

CONCLUSIONS

These preliminary results suggest qEEG metrics correlate with outcome. In some patients, qEEG patterns change over the first three days post-arrest.

Gender Disparities Among Adult Recipients of Bystander Cardiopulmonary Resuscitation in the Public

BACKGROUND

Bystander cardiopulmonary resuscitation (BCPR) improves survival from out-of-hospital cardiac arrest (OHCA), yet BCPR rates remain low. It is unknown whether BCPR delivery disparities exist based on victim gender. We measured BCPR rates by gender in private and public environments, hypothesizing that females would be less likely than males to receive BCPR in public settings, with an associated difference in survival to hospital discharge.

METHODS AND RESULTS

We analyzed data from adult, nontraumatic OHCA events within the Resuscitation Outcomes Consortium registry (2011-2015). Using logistic regression, we modeled the likelihood of receiving BCPR by gender, including patient-level variables, stratified by location. A cohort of 19 331 OHCAs was assessed. Mean age was 64±17 years, and 63% (12 225/19 331) were male. Overall, 37% of OHCA victims received bystander CPR. In public locations, 39% (272/694) of females and 45% (1170/2600) of males received BCPR ( P<0.01), whereas in private settings, 35% (2198/6328) of females and 36% (3364/9449) of males received BCPR ( P=NS). Among public OHCAs, males had significantly increased odds of receiving BCPR compared with females (odds ratio, 1.27; 95% CI, 1.05-1.53; P=0.01); this was not the case in the private setting (odds ratio, 0.93; 95% CI, 0.87-1.01; P=NS). Controlling for site, age, and race, BCPR was significantly associated with survival to hospital discharge (odds ratio, 1.69; 95% CI, 1.54-1.85; P<0.01); in this model, males had 29% increased odds of survival compared with females (odds ratio, 1.29; 95% CI, 1.17-1.42; P<0.01).

CONCLUSIONS

Males had an increased likelihood of receiving BCPR compared with females in public. BCPR improved survival to discharge, with greater survival among males compared with females.

Patient, Neighborhood, and Spatial Determinants of Out-of-Hospital Cardiac Arrest Outcomes Throughout the Chain of Survival: A Community-Oriented Multilevel Analysis

Objective: Global and national trends of out-of-hospital cardiac arrest (OHCA) have been examined; however, geographic variation and socioeconomic disparities of OHCA outcomes in the community setting are less understood. We developed and tested a replicable, community-oriented assessment strategy aimed to identify spatial variations in OHCA outcomes using socioeconomic, prehospital, and in-hospital factors. Methods: Emergency medical service (EMS) records of adult, non-traumatic OHCA within Alachua County, FL (2012-2017) were retrospectively reviewed and matched to corresponding medical records at the University of Florida (UF). Incidence of cardiac arrest was geocoded to census tracts and connected to U.S. census socioeconomic attribute data. Primary outcomes include survival to emergency department (ED), hospital admission, discharge, and discharge to home. Multilevel mixed-effects logistic regression models were developed to assess sub-county geographic variance, probabilities of survival, and prehospital risk factors. Getis-Ord Gi statistic and Moran's I-test was applied to assess spatial clustering in outcome survival rates. Results: Of the 1562 OHCA cases extracted from EMS records, 1,335 (85.5%) were included with 372 transported to study site. Predicted probability of survival to ED was 57.0% (95CI: 51.3-62.3%). Of transported cases to study site ED, predicted probabilities of survival was to 41.7% (95CI: 36.1-47.6%) for hospital admission, 16.1% (95CI: 10.7-23.5%) for hospital discharge, and 7.1% (95CI: 3.7-13.3%) for home discharge. Census tracts accounted for significant variability in survival to ED (p < 0.001), discharge (p = 0.031), and home discharge outcomes (p = 0.036). There was no significant geographic variation in survival to admission outcome. Neighborhood-level factors significantly improved model fit for survival to ED, discharge, and discharge home outcomes. Multiple modifiable patient- and neighborhood-level variables of interest were identified, including rural-urban differences. Conclusion: We identified important geographic disparities that exist in OHCA outcomes at the community level. By using a replicable schematic, this variation can be explained through community-oriented modifiable socioeconomic and prehospital factors.

Targeted Temperature Management for In-Hospital Cardiac Arrest: 6 Years of Experience

Targeted temperature management (TTM) is widely used for postcardiac arrest management of patients with out-of-hospital cardiac arrest. However, the use of TTM for patients with in-hospital cardiac arrest (IHCA) is controversial. The aim of this study was to investigate the role of TTM in the management of patients with IHCA. The medical records of all IHCA patients who were resuscitated and returned to spontaneous circulation from January 2011 to December 2016 were reviewed. After excluding patients with new do not resuscitate orders and those who died within 24 hours, 262 patients were eligible for analysis. Thirty-five of the 262 patients (13.3%) received TTM after IHCA. Patients who received TTM and standard supportive care (SSC) had similar baseline epidemiological status. The TTM patients were older and had a longer cardiac pulmonary resuscitation duration; however, the differences were not statistically significant. The 28-day survival rate was not significantly different between groups (12/35 in the TTM group [34%] vs. 114/225 in the SSC group [50%], p = 0.079). In the patients with good neurological status before arrest (Glasgow-Pittsburgh cerebral performance category [GP-CPC] scores: 1-2), there was no significant difference in the 28-day survival between groups (11/26 in the TTM group [42.3%] vs. 81/154 [52.6%] in the SSC group; p = 0.332). In this subgroup, the TTM patients had poorer neurological outcomes at discharge (GP-CPC score 1-2) than the SSC patients (1/26 in the TTM group [3.8%] vs. 57/154 in the SSC group [37%]; p = 0.001). TTM was not associated with better 28-day survival than usual care among the patients with IHCA in this study, and the TTM patients had less favorable neurological outcomes at discharge. Randomized clinical trials are needed to assess the efficacy of TTM for IHCA patients.

The Compliance of Current Small Animal CPR Practice With RECOVER Guidelines: An Internet-Based Survey

In 2012 the Reassessment Campaign on Veterinary Resuscitation (RECOVER) published evidence-based treatment recommendations for dogs and cats with cardiopulmonary arrest (CPA), to optimize the clinical practice of small animal CPR and positively impact outcomes. Six years after the release of these guidelines, we aimed to determine the compliance of small animal veterinary CPR practices with these RECOVER guidelines. To identify current CPR practices in clinically active small animal veterinarians and their awareness of the RECOVER guidelines, we conducted an internet-based survey. Survey invitations were disseminated internationally via veterinary professional organizations and their social media outlets. Questions explored respondent demographics, CPR preparedness, BLS and ALS techniques and awareness of RECOVER guidelines. Responding small animal veterinarians (n = 770) in clinical practice were grouped by level of expertise: board-certified specialists (BCS, n = 216) and residents (RES, n = 69) in anesthesia or emergency and critical care, practitioners in emergency (GPE, n = 299) or general practice (GPG, n = 186). Large disparities in preparedness measures, BLS and ALS techniques emerged among levels of expertise. Only 32% (95% CI: 29–36%) of respondents complied with BLS practice guidelines, varying from 49% (95% CI: 42–55%) of BCS to 15% (95% CI: 10–20%) of GPG. While incompliances in BCS, RES, and GPE were predominantly due to knowledge gaps, GPG compliance was further compromised by limitations in the resuscitation environment (e.g., defibrillator availability, team size). Those aware of RECOVER guidelines (100% of BCS and RES; 77% of GPE; 35% of GPG) were more likely to comply with recommended preparedness (OR = 2.4; 95% CI: 1.2–4.8), BLS (OR = 4.5; 95% CI: 2.4–9.1), and ALS techniques (OR = 7.8; 95% CI: 2.4–9.1) independent of age, gender, region of practice or level of expertise. We conclude that awareness of RECOVER guidelines is high in specialists and residents, but incomplete among general practitioners. This awareness positively influenced compliance with CPR guidelines, but CPR practices continue to be variable and largely not in agreement with guidelines. A widely accessible educational strategy is required to broadly improve compliance with best practices in small animal CPR.

Relation of multicenter automatic defibrillator implantation trial implantable cardioverter-defibrillator score with long-term cardiovascular events in patients with implantable cardioverter-defibrillator

OBJECTIVE

To test the hypothesis that multicenter automatic defibrillator implantation trial (MADIT) - implantable cardioverter-defibrillator (ICD) scores predict replacement requirement and appropriate shock in a mixed population including both primary and secondary prevention and long-term adverse cardiovascular events.

METHODS

The study has a retrospective design. Patients who were implanted with ICD in the cardiology clinic of Atatürk University Faculty of Medicine between 2000 and 2013 were included in the study. For this purpose, 1394 patients who were implanted with a device in our clinic were reviewed. Then, those who were implanted with permanent pacemaker (n=1005), cardiac resynchronization treatment (CRT) (n=45) and CRT-ICD (n=198) were excluded.

RESULTS

A total of 146 patients (98 males, 67.1%) with a mean age of 61.1 (±14.8) years were recruited. The median follow-up time was 21.5 months (mean 30.6±25.9 months; minimum 4 months, and maximum 120 months). The median MADIT-ICD scores in the patients were 2. MADIT-ICD scores were categorized as low in 15.1%, intermediate in 57.5%, and high score in 27.4% of patients. Accordingly, MADIT-ICD scores (1.29 [1.00-1.68], p=0.050), hemoglobin (0.86 [0.75-0.99], p=0.047), and left ventricular ejection fraction (EF) (0.97 [0.94-0.99], p=0.023) were determined as independent predictors of major adverse cardiovascular events in the long-term follow-up of ICD-implanted population.

CONCLUSION

In this study, we showed that there was an independent association of long-term adverse cardiovascular events with MADIT-ICD score, hemoglobin, and EF in patients implanted with ICD.

Public access of automated external defibrillators in a metropolitan city of China

BACKGROUND

Public access of automated external defibrillator (AED) is an important public health strategy for improving survival of cardiac arrest. Major metropolitan cities in China are increasingly investing and implementing public access defibrillator programs, but the effectiveness of these programs remains unclear. This study aims to evaluate the public accessibility of AED in Shanghai, a major metropolitan city in China.

METHODS

From July 1 to September 30, 2018, all AED locations indicated by AED Access Map Apps were visited and investigated in three most densely distributing areas of AED (Huangpu District, Xuhui District, and Central Area of the Pudong New District) in Shanghai. Two AED Access Map APPs were used to identify the location of AEDs. Characteristics of and the barriers to access, the AED sites were recorded. Awareness and skills of first aid and AED among on-site staff of the AED installation sites were evaluated.

RESULTS

A total of 283 sites were marked on two AED Apps. One hundred and seventy (60%) locations were accessible, and 142 (50%) were actually with AEDs installed. Among those AED installed sites, 112 (79%) were completely identifiable to the information on the maps, 20 (14%) were inconsistent and 10 (7%) were inaccurate on the maps. Ninety-four (66%) AEDs had visible signs and information around the location, 7 (5%) AEDs had signs outside of the location, and 107 (75%) sites had educational instructions. In addition, 230 individuals who were around the AED site were interviewed. Among them, 79 (34%) had good knowledge of AED. After shown the picture of AED, 112 (49%) knew whether there was AED in the site, and 108 (47%) knew the AED's location. Eighty-seven (38%) staff have received first aid training, and among them 26 (30%) reported that they had skills in operating the AED.

CONCLUSIONS

Public placement and accessibility of AEDs, related public signs and information on AED, and staff's awareness about AED were not optimal in Shanghai. Continuing efforts should be made to improve public accessibility and public awareness, knowledge, and user skills of AED.

Outcomes and modifiable resuscitative characteristics amongst pan-Asian out-of-hospital cardiac arrest occurring at night

Studies are divided on the effect of day-night temporal differences on clinical outcomes in out-of-hospital cardiac arrest (OHCA). This study aimed to elucidate any differences in OHCA survival between day and night occurrence, and the factors associated with differences in survival.This was a prospective, observational study of OHCA cases across multinational Pan-Asian sites. Cases were divided according to time call received by dispatch centers into day (0700H-1900H) and night (1900H-0659H). Primary outcome was 30-day survival. Secondary outcomes were prehospital and hospital modifiable resuscitative characteristics.About 22,501 out of 55,881 cases occurred at night. Night cases were less likely to be witnessed (40.2% vs. 43.1%, P < .001), more likely to occur at home (32.5% vs. 29%, P < .001), had non-shockable initial rhythms (90.8% vs. 89.4%, P < .001), lower bystander CPR rates (36.2 vs. 37.6%, P = .001), lower bystander AED application rate (0.3% vs. 0.7%, P < .001), lower rates of prehospital defibrillation (13% vs. 14.4%, P < .001), and were less likely to receive prehospital adrenaline (9.8% vs. 11%, P < .001). 30-day survival at night was lower with an adjusted odds ratio of 0.79 (95% CI 0.73-0.86, P < .001). On multivariate logistic regression, occurrence at night was associated with decreased provision of bystander CPR, bystander AED application, and prehospital adrenaline.30-day survival was worse in OHCA occurring at night. There were circadian patterns in incidence. Bystander CPR and bystander AED application were significantly lower at night in multivariate analysis. This would at least partially explain the decreased survival at night.

Confirming the Clinical Safety and Feasibility of a Bundled Methodology to Improve Cardiopulmonary Resuscitation Involving a Head-Up/Torso-Up Chest Compression Technique

OBJECTIVES

Combined with devices that enhance venous return out of the brain and into the thorax, preclinical outcomes are improved significantly using a synergistic bundled approach involving mild elevation of the head and chest during cardiopulmonary resuscitation. The objective here was to confirm clinical safety/feasibility of this bundled approach including use of mechanical cardiopulmonary resuscitation provided at a head-up angle.

DESIGN

Quarterly tracking of the frequency of successful resuscitation before, during, and after the clinical introduction of a bundled head-up/torso-up cardiopulmonary resuscitation strategy.

SETTING

9-1-1 response system for a culturally diverse, geographically expansive, populous jurisdiction.

PATIENTS

All 2,322 consecutive out-of-hospital cardiac arrest cases (all presenting cardiac rhythms) were followed over 3.5 years (January 1, 2014, to June 30, 2017).

INTERVENTIONS

In 2014, 9-1-1 crews used LUCAS (Physio-Control Corporation, Redmond, WA) mechanical cardiopulmonary resuscitation and impedance threshold devices for out-of-hospital cardiac arrest. After April 2015, they also 1) applied oxygen but deferred positive pressure ventilation several minutes, 2) solidified a pit-crew approach for rapid LUCAS placement, and 3) subsequently placed the patient in a reverse Trendelenburg position (~20°).

MEASUREMENTS AND MAIN RESULTS

No problems were observed with head-up/torso-up positioning (n = 1,489), but resuscitation rates rose significantly during the transition period (April to June 2015) with an ensuing sustained doubling of those rates over the next 2 years (mean, 34.22%; range, 29.76-39.42%; n = 1,356 vs 17.87%; range, 14.81-20.13%, for 806 patients treated prior to the transition; p < 0.0001). Outcomes improved across all subgroups. Response intervals, clinical presentations and indications for attempting resuscitation remained unchanged. Resuscitation rates in 2015-2017 remained proportional to neurologically intact survival (~35-40%) wherever tracked.

CONCLUSIONS

The head-up/torso-up cardiopulmonary resuscitation bundle was feasible and associated with an immediate, steady rise in resuscitation rates during implementation followed by a sustained doubling of the number of out-of-hospital cardiac arrest patients being resuscitated. These findings make a compelling case that this bundled technique will improve out-of-hospital cardiac arrest outcomes significantly in other clinical evaluations.

Comparison of Outcomes and Characteristics of Emergency Medical Services (EMS)-Witnessed, Bystander-Witnessed, and Unwitnessed Out-of-Hospital Cardiac Arrests in Singapore

Objectives: The objective was to compare the survival outcomes of emergency medical services (EMS)-witnessed to bystander-witnessed, and unwitnessed out-of-hospital cardiac arrests (OHCA) in Singapore. Secondary aims are to describe the 5-year trend in survival rates of EMS-witnessed arrests. Methods: This was a retrospective analysis of the Singapore's OHCA registry data from 2011 to 2015. Excluded from the analysis were patients younger than 18 years old, arrests of traumatic etiology, resuscitation not attempted, and cases not conveyed by EMS. The primary outcome was survival to hospital discharge or 30 days post-arrest. Secondary outcomes were return of spontaneous circulation (ROSC) and survival to hospital admission. Results: 8,394 cases were analyzed, with 650 (7.7%) EMS-witnessed arrests, 4480 (53.4%) bystander-witnessed arrests, and 3264 (38.9%) unwitnessed arrests. Among EMS-witnessed arrests, the majority were presumed to be of cardiac etiology (62.8%) and the most common presenting rhythm was pulseless electrical activity (PEA; 57.2%). Survival to discharge or 30^th day post-arrest was higher in EMS-witnessed arrests compared to bystander-witnessed and unwitnessed arrests (11.2% vs. 5.3% and 1.3%, p < 0.001). Survival to discharge for EMS-witnessed cases increased from 2011 (13.2%) to 2015 (18.9%). Conclusions: EMS-witnessed OHCAs were more likely to have favorable outcomes compared to bystander-witnessed and unwitnessed OHCAs. High PEA rates in EMS-witnessed arrests were associated with older patients with underlying preexisting medical conditions. Increasing public awareness on recognition of prodromal symptoms and early activation of EMS could improve post-arrest survival and neurological outcomes of OHCA.

Evaluation of culture-specific popular music as a mental metronome for cardiopulmonary resuscitation: a randomised crossover trial

Introduction:

Bystander cardiopulmonary resuscitation (CPR) improves survival in out-of-hospital cardiac arrest. The use of certain songs as mental metronomes for CPR have been validated and recognised by contemporary guidelines. We hypothesise that the National Day song, Count on me Singapore (COMS CPR), is not inferior to standard ‘one-and-two-and-three-and-four’ counting (standard CPR) for timing CPR, in terms of the proportion of participants achieving the guideline compression rate of 100–120/minute.

Methods:

This was a prospective randomised crossover trial powered to demonstrate non-inferiority in the CPR rate. After a familiarisation session, volunteers were randomly assigned to two groups. Group A performed one cycle of standard CPR while group B performed one cycle of COMS CPR. Participants then crossed over to perform the other method. The Laerdal SkillReporter measured CPR quality. Four weeks later, participants attended a test scenario, using standard CPR or COMS CPR (randomly allocated).

Results:

Ninety subjects were recruited; 46 were randomly assigned to group A and 44 to group B. Baseline characteristics were similar; 41.1% of COMS CPR achieved 100–120/minute, versus 28.9% of standard CPR ( P=0.028). In mixed effects logistical regression, significantly more COMS CPR was performed at 100–120/minute compared to standard CPR (odds ratio 2.44, 95% confidence interval 1.01–5.9, P=0.047). The proportion of insufficient depth was higher in COMS CPR (80.59% vs. 68.01%, P<0.001). There were no differences in other aspects of CPR quality. There were no differences in CPR quality between standard CPR and COMS CPR during the follow-up.

Conclusion:

COMS CPR was not inferior in terms of the proportion of participants delivering a guideline-compliant rate of chest compression. COMS CPR may have applications to layman CPR education, such as in mass education events.

Nighttime is associated with decreased survival for out of hospital cardiac arrests: A meta-analysis of observational studies

INTRODUCTION

The relationship between time of day and the clinical outcomes of patients with out-of-hospital cardiac arrest (OHCA) remains inconclusive. We undertook a meta-analysis to assess the available evidence on the relationship between nighttime and prognosis for patients with OHCA.

MATERIALS AND METHODS

PubMed and EMBASE were searched through June 20, 2018, to identify all studies assessing the relationship between nighttime and prognosis for patients with OHCA. Random effects modes were used to estimate odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

Eight observational studies met the inclusion criteria. Meta-analysis of 8 studies showed that compared with nighttime, the daytime OHCA patients had higher 1-month/in-hospital survival (OR, 1.25; 95% CI, 1.15-1.37; P = 0.00), with high heterogeneity among the studies (I² = 82.8%, P = 0.00).

CONCLUSIONS

Patients who experienced OHCA during the nighttime had lower 1-month/in-hospital survival than those with daytime OHCA. In addition to arrest event and pre-hospital care factors, patients' comorbidity and hospital-based care may also be responsible for lower survival at night.

Notas sobre <em>Tanacetum corymbosum s. l.</em> (Asteraceae)

Se presenta un estudio nomenclatural y taxonómico sobre Chrysanthemum italicum L., C. achilleae L., C. tanacetifolium Pourr., Pyrethrum cinereum Griseb., P. clusii Fisch. ex Rchb., P. clusii Tausch, P. daucifolium Pers. y P. tenuifolium Ten., táxones que pertenecen al grupo crítico de Tanacetum corymbosum. Se propone una nueva clasificación infraespecífica de Tanacetum corymbosum (L.) Sch. Bip. s. l. y se reconocen cinco subespecies sobre la base de un estudio morfológico del material tipo y otros especímenes. Se proporciona una clave de diagnóstico de los táxones estudiados. Se propone también un cambio nomenclatural, i.e. Tanacetum corymbosum subsp. daucifolium (Pers.) Iamonico comb. nov. Se designan lectotipos para los nombres Chrysanthemum cinereum (espécimen conservado en GOET), Chrysanthemum achilleae (imagen de Micheli), Chrysanthemum italicum (en LINN), Pyrethrum clusii de Rechenbach (ilustración de Clusius), Pyrethrum tenuifolium (en G) y Pyrethrum clusii de Tausch (imagen de Clusius). Se designa un neotipo para Chrysanthemum tanacetifolium (en P).

A Smartphone Application to Reduce the Time to Automated External Defibrillator Delivery After a Witnessed Out-of-Hospital Cardiac Arrest: A Randomized Simulation-Based Study

INTRODUCTION

We developed a new smartphone application to deliver an automated external defibrillator (AED) to out-of-hospital cardiac arrest scene. The aim of this study was to evaluate whether an AED could be delivered earlier with or without an application in a simulated randomized controlled trial.

METHODS

Participants, who were asked to work as bystanders, were randomly assigned to either an application group or control group and were asked to bring an AED in both groups. The bystanders in the application group sent a signal notification using the application to two responders, who were stationed within 200 meters of the arrest scene, to carry an AED. The primary outcome was the AED delivery time by either the bystander or his/her responder.

RESULTS

In total, 61 bystanders were eligible and randomized to either the application group (32) or the control group (29). The 52 with time data were available and analyzed. The AED delivery time by either the bystander or his/her responder was significantly shorter in the application group than in the control group [133.6 (44.4) seconds vs. 202.2 (122.2) seconds, P = 0.01].

CONCLUSIONS

In this simulation-based trial, AED delivery time was shortened by our newly developed smartphone application for the bystander to ask nearby responders to find and bring an AED to the cardiac arrest scene (UMIN-Clinical Trials Registry 000016506).

The Critical Role of Dispatch

There are 240 million 9-1-1 calls in the United States every year. The burden of managing these emergencies until first responders can arrive is on the dispatchers working in the 5806 public safety answering points, more commonly known as dispatch centers. They are the first link in the chain of survival between the public and the remainder of the health care system. Dispatchers play a critical role in the early identification of emergencies, assignment of appropriate emergency resources, and provision of life-sustaining interventions like dispatcher-assisted cardiopulmonary resuscitation and disaster management.

Changes in automated external defibrillator use and survival after out-of-hospital cardiac arrest in the Nijmegen area

Purpose

Out-of-hospital cardiac arrests (OHCAs) are a major healthcare problem. Over the years, several initiatives have contributed to more lay volunteers providing cardiopulmonary resuscitation (CPR) and increased use of automated external defibrillators (AEDs) in the Netherlands. As part of a quality and outcomes program, we registered bystander CPR, AED use and outcome in the Nijmegen area.

Methods

Prospective resuscitation registry with a study cohort of non-traumatic OHCA cases from 2013–2016 and historical controls from 2008–2011. In line with previous reports, we studied patients transported to the hospital (Radboudumc, Nijmegen, the Netherlands) and excluded arrests witnessed by the emergency medical service (EMS). Primary outcomes were return of spontaneous circulation (ROSC) and survival to discharge.

Results

In the study cohort (n = 349) the AED was attached more often than in the historical cohort (n = 180): 46% vs. 23% and the proportion of bystander CPR was higher: 78% vs. 63% (both p < 0.001). A higher proportion of patients received an AED shock (39% vs. 15%, p < 0.001) and the number of required shocks by the EMS was lower (2 vs. 4, p = 0.004). Survival to discharge was higher (47% vs. 33%, p = 0.002) without differences in ROSC. The survival benefit was restricted to patients with a shockable initial rhythm. In both cohorts, bystander CPR and AED use were independently associated with survival.

Conclusion

In patients admitted after OHCA, survival to discharge has markedly improved to 40–50%, comparable with other Dutch registries. As increased bystander CPR and the doubled use of AEDs seem to have contributed, all civilian-based resuscitation initiatives should be encouraged.

Outcome of conscious survivors of out-of-hospital cardiac arrest

AIM

Only up to 20% of patients with out-of-hospital cardiac arrest (OHCA) receive immediate and optimal initial cardiac resuscitation and consequently regain consciousness soon after return of spontaneous circulation (ROSC). In the present study, we compared the outcome of conscious survivors of OHCA presenting with ST-elevation myocardial infarction (STEMI) in post-resuscitation electrocardiogram undergoing immediate invasive coronary strategy with randomly selected STEMI patients without preceding OHCA undergoing primary PCI.

METHODS

We conducted a single-centre registry-based analysis of all conscious OHCA survivors with STEMI over the last 10 year period. We gathered clinical and angiographic data and compared them with a randomly selected cohort of non-OHCA patients with STEMI within the same period. Patients were matched by sex, age and STEMI location.

RESULTS

86 conscious survivors of OHCA were admitted between 2006 and 2016. OHCA was witnessed in all patients (85% EMS witnessed), and all patients presented with initial shockable rhythm. Clinical and angiographic features were well matched with randomly selected STEMI patients without OHCA presenting to our department within the same study period. Delay from symptoms to EMS arrival but not delay from EMS to PCI was significantly shorter in conscious OHCA survivors (1.2 ± 1.3 h vs 3.1 ± 3.8 h, p < 0.001), yielding decreased total myocardial ischemic time (2.6 ± 1.3 h vs 4.6 ± 4.0 h, p < 0.001). Hospital and 1-year survival with normal neurological condition in conscious survivors of OHCA (cerebral performance category 1) was excellent and numerically even better than survival of STEMI patients without OHCA.

CONCLUSION

Conscious survivors of OHCA with STEMI have excellent survival if they undergo immediate invasive coronary strategy. Since there is no obvious post-resuscitation brain injury in this subgroup of OHCA patients, it is probably shorter duration of myocardial ischemia driven by shorter delay from symptoms to EMS arrival that contributes to the good outcome, which is at least similar to STEMI patients without OHCA.

The Pan-Asian Resuscitation Outcomes Study (PAROS) clinical research network: what, where, why and how

Out-of-hospital cardiac arrest (OHCA) is a global health concern with an incidence rate of 50-60 per 100,000 person-years. To improve OHCA survival rates, several cardiac arrest registries have been set up in North America and Europe, such as the Resuscitation Outcomes Consortium, Cardiac Arrest Registry to Enhance Survival, Ontario Prehospital Advanced Life Support and European Registry of Cardiac Arrest. In Asia, however, there was previously no concerted effort in prehospital emergency care research owing to differences in prehospital emergency medical services systems, data collection methods and outcome reporting between countries. Recognising the need for a collaborative prehospital emergency care research group in Asia, researchers from seven countries in the Asia-Pacific region (including Japan, South Korea, Taiwan, Thailand, United Arab Emirates-Dubai, Singapore and Malaysia) established the Pan-Asian Resuscitation Outcomes Study (PAROS) clinical research network in 2010. This paper gives the overview, methodology and research accomplishments of the PAROS network.

Epidemiology of out-of-hospital cardiac arrest: A French national incidence and mid-term survival rate study

Out-of-hospital cardiac arrest (OHCA) is considered an important public health issue but its incidence has not been examined in France. The aim of this study is to define the incidence of OHCA in France and to compare this to other neighbouring countries. Data were extracted from the French OHCA registry. Only exhaustive centres during the period from January 1, 2013, to September 30, 2014 were included. All patients were included, regardless of their age and cause of OHCA. The participating centres covered about 10% of the French population. The study involved 6918 OHCA. The median age was 68 years, with 63% of males. Paediatric population (<15years) represented 1.8%. The global incidence of OHCA was 61.5 per 100,000 inhabitants per year in the total population corresponding to approximately 46,000 OHCA per year. In the adult population, we found an incidence of 75.3 cases per 100,000 inhabitants per year. In adults, the incidences were 100.3 and 52.7 in males and females, respectively. Most (75%) OHCA occurred at home and were due to medical causes (88%). Half of medical OHCA had cardiovascular causes. Survival rates at 30 days was 4.9% [4.4; 5.4] and increased to 10.4% [9.1; 11.7] when resuscitation was immediately performed by bystander at patient's collapse. The incidence and survival at 30 days of OHCA in France appeared similar to that reported in other European countries. Compared to other causes of deaths in France, OHCA is one of the most frequent causes, regardless of the initial pathology.

Protocol of a Multicenter International Randomized Controlled Manikin Study on Different Protocols of Cardiopulmonary Resuscitation for laypeople (MANI-CPR)

INTRODUCTION

Out-of-hospital cardiac arrest is one of the leading causes of death in industrialised countries. Survival depends on prompt identification of cardiac arrest and on the quality and timing of cardiopulmonary resuscitation (CPR) and defibrillation. For laypeople, there has been a growing interest on hands-only CPR, meaning continuous chest compression without interruption to perform ventilations. It has been demonstrated that intentional interruptions in hands-only CPR can increase its quality. The aim of this randomised trial is to compare three CPR protocols performed with different intentional interruptions with hands-only CPR.

METHODS AND ANALYSIS

This is a prospective randomised trial performed in eight training centres. Laypeople who passed a basic life support course will be randomised to one of the four CPR protocols in an 8 min simulated cardiac arrest scenario on a manikin: (1) 30 compressions and 2 s pause; (2) 50 compressions and 5 s pause; (3) 100 compressions and 10 s pause; (4) hands-only. The calculated sample size is 552 people. The primary outcome is the percentage of chest compression performed with correct depth evaluated by a computerised feedback system (Laerdal QCPR). ETHICS AND DISSEMINATION: . Due to the nature of the study, we obtained a waiver from the Ethics Committee (IRCCS Policlinico San Matteo, Pavia, Italy). All participants will sign an informed consent form before randomisation. The results of this study will be published in peer-reviewed journal. The data collected will also be made available in a public data repository.

TRIAL REGISTRATION NUMBER

NCT02632500.

Short-term Results From a Training Program to Improve Organ Donation in Uncontrolled Donation After Circulatory Death

BACKGROUND

In all organ transplantation programs, election of the proper protocol relies primarily on the professionals involved in the detection of potential donors. The objective of our study was to assess the impact of a series of prehospital training sessions, as well as to develop several positive feedback strategies within the uncontrolled organ donation after circulatory death (uDCD) program in our city.

METHODS

A before-after intervention study was carried out in 3 steps. First, professionals enrolled in the Emergency Health Services Agency-061 (EPES-061) program underwent specific training to identify potential donors. Second, a specific logotype was designed to alert emergency health care professionals that in cases where cardiopulmonary resuscitation was ineffective and after treatment of all potentially reversible causes, the "chain of survival" should be considered a "chain of opportunities." Third, a positive feedback strategy was put in place, whereby each time a donation was procured, the EPES-061 personnel that had identified the potential donor were notified by phone and in a personal letter.

RESULTS

The mean age for donors was 50.5 years of age (interquartile range 37-52.5), and 89.5% of all donations came from male subjects. Positive feedback letters and phone calls, including information on final outcome, were provided to the appropriate personnel in 100% of the cases. Postintervention information showed an increase in both eligible and utilized donors.

CONCLUSIONS

Interventions outside the hospital setting that facilitate optimal implementation of the uDCD program are an essential part of this strategy to increase the donor pool and make the wait shorter for transplant patients.

[Assessment of professional practices in treating cardiac arrest]

An assessment of professional practices was carried out in 2013-2014 with the aim of improving the treatment of cardiac arrest in hospitals. Two methods were used: an assessment by questionnaire to evaluate theoretical knowledge and a practical assessment of external cardiac massage. The results highlight the need for greater knowledge. The use of cardiac massage must be included in continuing professional development.

Out-of-hospital cardiac arrest: prehospital management

Sudden out-of-hospital cardiac arrest is the most time-critical medical emergency. In the second paper of this Series on out-of-hospital cardiac arrest, we considered important issues in the prehospital management of cardiac arrest. Successful resuscitation relies on a strong chain of survival with the community, dispatch centre, ambulance, and hospital working together. Early cardiopulmonary resuscitation and defibrillation has the greatest impact on survival. If the community response does not restart the heart, resuscitation is continued by emergency medical services' staff. However, the best approaches for airway management and the effectiveness of currently used drug treatments are uncertain. Prognostic factors and rules for termination of resuscitation could guide the duration of a resuscitation attempt and decision to transport to hospital. If return of spontaneous circulation is achieved, the focus of treatment shifts to stabilisation, restoration of normal physiological parameters, and transportation to hospital for ongoing care.

Out-of-hospital cardiac arrest: current concepts

Out-of-hospital cardiac arrest (OHCA) is a leading cause of global mortality. Regional variations in reporting frameworks and survival mean the exact burden of OHCA to public health is unknown. Nevertheless, overall prognosis and neurological outcome are relatively poor following OHCA and have remained almost static for the past three decades. In this Series paper, we explore the aetiology of OHCA. Coronary artery disease remains the predominant cause, but there is a diverse range of other potential cardiac and non-cardiac causes to be aware of. Additionally, we describe how investigators and key stakeholders in resuscitation science have formulated specific Utstein data element domains in an attempt to standardise the definitions and outcomes reported in OHCA research so that management pathways can be improved. Finally, we identify the predictors of survival after OHCA and what primary and secondary prevention strategies can be instigated to mitigate the devastating sequelae of this growing public health issue.

The Current Status of Development and Implementation of Medical Emergency Response Plan in Schools

BACKGROUND

Automated external defibrillators (AEDs) have been widely distributed at schools in Japan. We have demonstrated that ventricular fibrillation accounted for 68% of nontraumatic sudden cardiac arrest (SCA) in schools, suggesting that a well-prepared medical emergency response plan (MERP) for schools would improve the outcomes of SCA patients. However, it is uncertain if the MERP has been well developed or implemented in Japanese schools.

METHODS AND RESULTS

We conducted a cross-sectional study of schools in Osaka using a postal questionnaire. Survey items included type of school, number of students, school staff and teaching staff, number of AEDs used and the place of installation, cardiopulmonary resuscitation (CPR) training to school staff, MERP development and implementation, and the number of SCA cases they experienced. The response rate to this survey was 44% (764 of 1728 schools). Every school except for 4 have installed at least 1 AED. Thirty-six percent of schools, however, have not yet developed and implemented a MERP for SCA. Moreover, 49% of schools surveyed have not conducted a rehearsal training session for SCA in the previous 3 years, although 95% of schools provided CPR training courses to school staff. A total of 15 schools have experienced 16 presumed or actual SCA cases in the study period. Of the 15 schools, 6 schools reported that bystanders experienced psychological stress.

CONCLUSIONS

A MERP for SCA has not yet been fully developed and implemented in the schools surveyed in our study despite widely distributed AEDs and CPR training.

Variation in outcome of hospitalised patients with out-of-hospital cardiac arrest from acute coronary syndrome: a cohort study

Background

Each year, approximately 30,000 people have an out-of-hospital cardiac arrest (OHCA) that is treated by UK ambulance services. Across all cases of OHCA, survival to hospital discharge is less than 10%. Acute coronary syndrome (ACS) is a common cause of OHCA.

Objectives

To explore factors that influence survival in patients who initially survive an OHCA attributable to ACS.

Data source

Data collected by the Myocardial Ischaemia National Audit Project (MINAP) between 2003 and 2015.

Participants

Adult patients who had a first OHCA attributable to ACS and who were successfully resuscitated and admitted to hospital.

Main outcome measures

Hospital mortality, neurological outcome at hospital discharge, and time to all-cause mortality.

Methods

We undertook a cohort study using data from the MINAP registry. MINAP is a national audit that collects data on patients admitted to English, Welsh and Northern Irish hospitals with myocardial ischaemia. From the data set, we identified patients who had an OHCA. We used imputation to address data missingness across the data set. We analysed data using multilevel logistic regression to identify modifiable and non-modifiable factors that affect outcome.

Results

Between 2003 and 2015, 1,127,140 patient cases were included in the MINAP data set. Of these, 17,604 OHCA cases met the study inclusion criteria. Overall hospital survival was 71.3%. Across hospitals with at least 60 cases, hospital survival ranged from 34% to 89% (median 71.4%, interquartile range 60.7–76.9%). Modelling, which adjusted for patient and treatment characteristics, could account for only 36.1% of this variability. For the primary outcome, the key modifiable factors associated with reduced mortality were reperfusion treatment [primary percutaneous coronary intervention (pPCI) or thrombolysis] and admission under a cardiologist. Admission to a high-volume cardiac arrest hospital did not influence survival. Sensitivity analyses showed that reperfusion was associated with reduced mortality among patients with a ST elevation myocardial infarction (STEMI), but there was no evidence of a reduction in mortality in patients who did not present with a STEMI.

Limitations

This was an observational study, such that unmeasured confounders may have influenced study findings. Differences in case identification processes at hospitals may contribute to an ascertainment bias.

Conclusions

In OHCA patients who have had a cardiac arrest attributable to ACS, there is evidence of variability in survival between hospitals, which cannot be fully explained by variables captured in the MINAP data set. Our findings provide some support for the current practice of transferring resuscitated patients with a STEMI to a hospital that can deliver pPCI. In contrast, it may be reasonable to transfer patients without a STEMI to the nearest appropriate hospital.

Future work

There is a need for clinical trials to examine the clinical effectiveness and cost-effectiveness of invasive reperfusion strategies in resuscitated OHCA patients of cardiac cause who have not had a STEMI.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

The chain of survival: Not all links are equal

The chain of survival aims to demonstrate the interrelationship between key stages of resuscitation and emphasises the need for all links to be effective in order to optimise the chances of survival. The contribution of each of the four links diminishes rapidly as patients succumb at each stage and the actual attrition rate results in rapidly decreasing numbers of patients progressing along the chain. This revised representation adjusts the area of each link in order to graphically represent the flow of patients through the chain. Greatest benefit in improving outcome will be achieved by focussing on improving care at links in the chain where there is the greatest number of patients.

Perceptions and experiences of community first responders on their role and relationships: qualitative interview study

BACKGROUND

Community First Responders (CFRs) are lay volunteers who respond to medical emergencies. We aimed to explore perceptions and experiences of CFRs in one scheme about their role.

METHODS

We conducted semi-structured interviews with a purposive sample of CFRs during June and July 2016 in a predominantly rural UK county. Interviews were transcribed verbatim and analysed using the Framework method, supported by NVivo 10.

RESULTS

We interviewed four female and 12 male adult CFRs aged 18-65+ years with different levels of expertise and tenures. Five main themes were identified: motivation and ongoing commitment; learning to be a CFR; the reality of being a CFR; relationships with statutory ambulance services and the public; and the way forward for CFRs and the scheme. Participants became CFRs mainly for altruistic reasons, to help others and put something back into their community, which contributed to personal satisfaction and helped maintain their involvement over time. CFRs valued scenario-based training and while some were keen to access additional training to enable them to attend a greater variety of incidents, others stressed the importance of maintaining existing abilities and improving their communication skills. They were often first on scene, which they recognised could take an emotional toll but for which they found informal support mechanisms helpful. Participants felt a lack of public recognition and sometimes were undervalued by ambulance staff, which they thought arose from a lack of clarity over their purpose and responsibilities. Although CFRs perceived their role to be changing, some were fearful of extending the scope of their responsibilities. They welcomed support for volunteers, greater publicity and help with fundraising to enable schemes to remain charities, while complementing the role of ambulance services.

DISCUSSION

CFR schemes should consider the varying training, development and support needs of staff. CFRs wanted schemes to be complementary but distinct from ambulance services. Further information on outcomes and costs of the CFR contribution to prehospital care is needed.

CONCLUSION

Our findings provide insight into the experiences of CFRs, which can inform how the role might be better supported. Because CFR schemes are voluntary and serve defined localities, decisions about levels of training, priority areas and targets should be locally driven. Further research is required on the effectiveness, outcomes, and costs of CFR schemes and a wider understanding of stakeholder perceptions of CFR and CFR schemes is also needed.

Emergency response readiness for primary school children

Objective The aim of the present study was to determine whether a 1-day basic life support (BLS) training program can significantly increase emergency response readiness for primary school children. Methods One hundred and seven children aged 11-12 years completed a program led by surf lifesaving instructors. A 50-item quiz was administered 1 week before and 1 and 8 weeks after training. Results Significant improvements were gained in knowledge of cardiopulmonary resuscitation (CPR; P<0.001), the response sequence for emergency situations (DRSABCD action plan) and various emergency scenarios, including choking (P<0.001) and severe bleeding (P<0.001). Knowledge and understanding were retained at the 8-week follow-up. Students reported increased confidence in assisting others after training, consistent with previous studies. Conclusions A 1-day training program can significantly increase BLS knowledge and confidence to provide assistance in an emergency situation. Findings reinforce the value of school-based training that provides a general foundation for emergency response readiness. What is known about this topic? The importance and value of teaching BLS to school children is well established in the US, UK and Europe. However, in the past 20 years there has been little or no published Australian evaluation research in this area, despite thousands of training programs running each year around the country for children in first aid, CPR and water safety. What does this paper add? This paper confirms that Australian primary school children can benefit significantly from short, targeted BLS training programs that provide the basic skills and confidence for them to respond in an emergency situation. What are the implications for practitioners? The paper provides a training and evaluation framework that can be used by health educators for age-appropriate BLS programs. The study shows that making training real-world and relevant, especially having hands-on CPR practice with manikins, can address common barriers to performing first aid and CPR reported by young people.

Analysis of functioning and efficiency of a code blue system in a tertiary care hospital

Background:

“Code blue” (CB) is a popular hospital emergency code, which is used by hospitals to alert their emergency response team of any cardiorespiratory arrest. The factors affecting the outcomes of emergencies are related to both the patient and the nature of the event. The primary objective was to analyze the survival rate and factors associated with survival and also practical problems related to functioning of a CB system (CBS).

Materials and Methods:

After the approval of hospital ethics committee, an analysis and audit was conducted of all patients on whom a CB had been called in our tertiary care hospital over 24 months. Data collected were demographic data, diagnosis, time of cardiac arrest and activation of CBS, time taken by CBS to reach the patient, presenting rhythm on arrival of CB team, details of cardiopulmonary resuscitation (CPR) such as duration and drugs given, and finally, events and outcomes. Chi-square test and logistic regression analysis were used to analyze the data.

Results:

A total of 720 CB calls were initiated during the period. After excluding 24 patients, 694 calls were studied and analyzed. Six hundred and twenty were true calls and 74 were falls calls. Of the 620, 422 were cardiac arrests and 198 were medical emergencies. Overall survival was 26%. Survival in patients with cardiac arrests was 11.13%. Factors such as age, presenting rhythm, and duration of CPR were found to have a significant effect on survival. Problems encountered were personnel and equipment related.

Conclusion:

A CBS is effective in improving the resuscitation efforts and survival rates after inhospital cardiac arrests. Age, presenting rhythm at the time of arrest, and duration of CPR have significant effect on survival of the patient after a cardiac arrest. Technical and staff-related problems need to be considered and improved upon.

Prehospital Resuscitation of Out-of-Hospital Cardiac Arrest in Queen Mary Hospital

Management of out-of-hospital cardiac arrest is a major task of the accident and emergency department. The aim of this study is to evaluate the efficacy of prehospital resuscitation of out-of-hospital cardiac arrest in Hong Kong and identify areas for improvement. It was a prospective descriptive study of adults with non-traumatic out-of-hospital cardiac arrest who were admitted to the Accident and Emergency Department of Queen Mary Hospital by the ambulance service from March 15, 1999 to October 15, 1999. Patient characteristics and the response times of the ambulance service were recorded according to the Utstein style. One hundred and thirty patients were included. The overall immediate survival rate was 14.6% and the overall survival to discharge rate was 1.54%. The outcome of out-of-hospital cardiac arrest is poor. Every link in the chain of survival has to be improved.

Strengthening Links in the “Chain of Survival”: A Singapore Perspective

Introduction

The concept of the chain of survival is widely accepted. The four links viz. early access, early cardiopulmonary resuscitation (CPR), early defibrillation and early Advanced Cardiac Life Support (ACLS) are related to survival after pre-hospital cardiac arrest. Owing to the dismal survival-to-discharge figures locally, we conducted this study to identify any weaknesses in the chain, looking in particular at bystander CPR rates and times to Basic Cardiac Life Support (BCLS) and ACLS.

Methods and materials

A retrospective cohort study was conducted in the Emergency Department of an urban tertiary 1500-bed hospital. Over a 12-month period, all cases of non-trauma out-of-hospital cardiac arrest were evaluated.

Results

A total of 142 cases of non-trauma out-of-hospital cardiac arrest were identified; the majority being Chinese (103/142, 72.5%) and male (71.8%) with a mean age of 64.3±7.8 years (range 23–89 yrs). Most patients (111/142, 78.2%) did not receive any form of life support until arrival of the ambulance crew. Mean time from collapse to arrival of the ambulance crew and initiation of BCLS and defibrillation was 9.2±3.5 minutes. Mean time from collapse to arrival in the Emergency Department (and thus ACLS) was 16.8±7.1 minutes. Three patients (2.11%) survived to discharge.

Conclusion

There is a need to (i) facilitate layperson training in bystander CPR, and (ii) enhance paramedic training to include ACLS, in order to improve the current dismal survival outcomes from out-of-hospital cardiac arrest in Singapore.

Comparison of Clinical Prediction Rules for Termination of Resuscitation of Out-of-Hospital Cardiac Arrests on Arrival to Emergency Department

Objective

To compare the discriminative capacities of various termination of resuscitation (TOR) rules in the prediction of futile resuscitation in the emergency department (ED).

Design

Prospective cohort study.

Setting

2 public hospitals in a cluster in Hong Kong.

Methods

The data were obtained from a Cardiac Arrest Registry of the EDs of two hospitals, including consecutive adult patients suffering from non-traumatic out-of-hospital cardiac arrest from 1st August 2010 to 30th June 2012. Those with return of spontaneous circulation before ED arrival and cases without resuscitation in the EDs were excluded. The modified basic life support (BLS), modified advanced life support (ALS) and neurologic TOR rules were applied to the cohort. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value were calculated. The outcome measures were survival to hospital admission (STA) and survival to discharge (STD).

Results

Totally 1125 cases were included. The mean age was 72.4. Return of spontaneous circulation and STA occurred in 302 patients and 9 had STD. Regarding the outcome of STD, the modified ALS and neurologic TOR rules had outperformed the modified BLS rule. The specificity and PPV were 100% for both rules in predicting death when the rules suggested TOR. Regarding the outcome of STA, the neurologic TOR rule had the highest specificity [84.4%; 95% confident interval (CI): 79.7-88.2%] and PPV (84.5%; 95% CI: 79.8-88.3%).

Conclusions

The modified ALS and neurologic TOR rules have similar discriminative capacities to predict STD. The neurologic TOR rule has the highest ability to predict STA in the ED. (Hong Kong j.emerg.med. 2013;20:343-351)

Training and Willingness to Perform Bystander Basic Life Support

Objectives

To evaluate the perceived ability and willingness of people to perform basic life support (BLS), to relate this to those most at risk of sudden cardiac death, and to identify groups of National Health Service (NHS) staff who could benefit from training in BLS.

Design

Prospective, survey.

Setting

The Accident and Emergency (A&E) department based at Glasgow Royal Infirmary.

Subjects

All patients, accompanying persons and NHS staff who were able, willing and waiting in the A&E department.

Methods

Subjects were asked to complete a proforma with questions relating to their experience and training in BLS. Their recognition of the importance of defibrillation in the light of current European guidelines for BLS was tested.

Results

718 proformas were completed. Fifty-seven percent non-clinical NHS staff had received no training in BLS. More than 50% subjects had relatives with risk factors of Ischaemic Heart Disease yet had no training in BLS. Seventy percent ambulance men and 50% clinical NHS personnel would perform mouth to mouth ventilation before calling an ambulance where they were required to perform BLS, as a bystander. Seventy percent non-clinical NHS personnel and non NHS subjects would call an ambulance first.

Conclusions

Non-clinical NHS personnel form a hospital based group that could be trained in BLS, some of whom could assume an instructor role. A proportion of clinical and emergency personnel would not prioritise an early call for a defibrillator over BLS in the out of hospital setting.

Is There Any Difference in Cardiopulmonary Resuscitation Performance According to Different Instructional Models of Cardiopulmonary Resuscitation Education for Junior and Senior High School Students?

Objective

This study aims to determine whether or not cardiopulmonary resuscitation (CPR) skills differ according to different instructional models for CPR education and training for junior and senior high school students.

Methods

This was a prospective and randomised study including 519 junior and senior high school students. After the lecture on CPR, students practiced the skill on the manikin. Group 1 used model 1 and Group 2 used model 2 for practical training and practical skills and CPR performance quality were evaluated.

Results

Data from skill tests were analysed in 229 students in group 1 and 210 students in group 2. The total score of sequence skill tests was 17.8±2.0 points. During 2 cycles, no chest elevation was observed in 33.3% and was significantly lower in group 1. There were no significant differences in the frequency of proper ventilation and in ventilation volume between the 2 groups. Excessive ventilation was more frequently observed in group 1 and insufficient ventilation was observed more frequently in group 2. The percentage of the frequency of a proper chest compression rate was 80.5±31.2% and there were no significant differences in proper and insufficient depths, mean rate and recoil of the chest in chest compression between the 2 groups.

Conclusions

There were differences in CPR skills according to different CPR training manikins. Therefore, certain conditions seem to be considered in selection of instructional models for CPR psychomotor skills. (Hong Kong j.emerg.med. 2011;18:375-382)

Interaction of defibrillation waveform with the time to defibrillation or the number of defibrillation attempts on survival from out-of-hospital cardiac arrest

AIM

Early biphasic defibrillation is effective in out-of-hospital cardiac arrest (OHCA) cases. In the resuscitation of patients with OHCA, it is not clear how the defibrillation waveform interacts with the time to defibrillation to influence patient survival. The second, and any subsequent, shocks need to be administered by an on-line physician in Japan. Thus, we investigated the interaction between the defibrillation waveform and time to or the number of defibrillation on resuscitation outcomes.

METHODS

This prospective observational study used data for all OHCAs that occurred between 2005 and 2014 in Japan. To investigate the interaction effect between the defibrillation waveform and the time to defibrillation or the number of defibrillations on the return to spontaneous circulation (ROSC), 1-month survival, and cerebral performance category (CPC) (1, 2), we assessed the modifying effects of the defibrillation waveform and the time to or the number of defibrillation on additive scale (i.e., the relative excessive risk due to interaction, RERI) and multiplicative scale (i.e., ratio of odds ratios (ORs)).

RESULTS

In total, 71,566 cases met the inclusion criteria. For the measure of interaction between the defibrillation waveform and the time to defibrillation, ratio of ORs for ROSC was 0.84 (0.75-0.94), implying that the effect of time to first defibrillation on ROSC was negatively modified by defibrillation waveform. For the interaction between the defibrillation waveform and the number of defibrillations, RERI and ratio of ORs for CPC (1, 2) was -0.25 (-0.47 to -0.06) and 0.79 (0.67-0.93), respectively. It is implied that the effect of number of defibrillation on CPC (1, 2) was negatively modified by defibrillation waveform.

CONCLUSIONS

An increased number of defibrillations was associated with a decreased ROSC in the case of biphasic and monophasic defibrillation, while an increased number of defibrillations was related to an increased 1-month survival rate and CPC (1, 2) only in the case of biphasic defibrillation. When two or more defibrillations were performed, a biphasic waveform was more effective in terms of long-term survival than a monophasic waveform.

Association of Public Health Initiatives With Outcomes for Out-of-Hospital Cardiac Arrest at Home and in Public Locations

Importance

Little is known about the influence of comprehensive public health initiatives according to out-of-hospital cardiac arrest (OHCA) location, particularly at home, where resuscitation efforts and outcomes have historically been poor.

Objective

To describe temporal trends in bystander cardiopulmonary resuscitation (CPR) and first-responder defibrillation for OHCAs stratified by home vs public location and their association with survival and neurological outcomes.

Design, Setting, and Participants

This observational study reviewed 8269 patients with OHCAs (5602 [67.7%] at home and 2667 [32.3%] in public) for whom resuscitation was attempted using data from the Cardiac Arrest Registry to Enhance Survival (CARES) from January 1, 2010, through December 31, 2014. The setting was 16 counties in North Carolina.

Exposures

Patients were stratified by home vs public OHCA. Public health initiatives to improve bystander and first-responder interventions included training members of the general population in CPR and in the use of automated external defibrillators, teaching first responders about team-based CPR (eg, automated external defibrillator use and high-performance CPR), and instructing dispatch centers on recognition of cardiac arrest.

Main Outcomes and Measures

Association of resuscitation efforts with survival and neurological outcomes from 2010 through 2014.

Results

Among home OHCA patients (n = 5602), the median age was 64 years, and 62.2% were male; among public OHCA patients (n = 2667), the median age was 68 years, and 61.5% were male. After comprehensive public health initiatives, the proportion of patients receiving bystander CPR increased at home (from 28.3% [275 of 973] to 41.3% [498 of 1206], P < .001) and in public (from 61.0% [275 of 451] to 70.5% [424 of 601], P = .01), while first-responder defibrillation increased at home (from 42.2% [132 of 313] to 50.8% [212 of 417], P = .02) but not significantly in public (from 33.1% [58 of 175] to 37.8% [93 of 246], P = .17). Survival to discharge improved for arrests at home (from 5.7% [60 of 1057] to 8.1% [100 of 1238], P = .047) and in public (from 10.8% [50 of 464] to 16.2% [98 of 604], P = .04). Compared with emergency medical services-initiated CPR and resuscitation, patients with home OHCA were significantly more likely to survive to hospital discharge if they received bystander-initiated CPR and first-responder defibrillation (odds ratio, 1.55; 95% CI, 1.01-2.38). Patients with arrests in public were most likely to survive if they received both bystander-initiated CPR and defibrillation (odds ratio, 4.33; 95% CI, 2.11-8.87).

Conclusions and Relevance

After coordinated and comprehensive public health initiatives, more patients received bystander CPR and first-responder defibrillation at home and in public, which was associated with improved survival.

Mechanical Cardiopulmonary Resuscitation and Hospital Survival Among Adult Patients With Nontraumatic Out-of-Hospital Cardiac Arrest Attending the Emergency Department: A Prospective, Multicenter, Observational Study in Japan (SOS-KANTO [Survey of Survivors after Out-of-Hospital Cardiac Arrest in Kanto Area] 2012 Study)

Background

Mechanical cardiopulmonary resuscitation (mCPR) for patients with out‐of‐hospital cardiac arrest attending the emergency department has become more widespread in Japan. The objective of this study is to determine the association between the mCPR in the emergency department and clinical outcomes.

Methods and Results

In a prospective, multicenter, observational study, adult patients with out‐of‐hospital cardiac arrest with sustained circulatory arrest on hospital arrival were identified. The primary outcome was survival to hospital discharge. The secondary outcomes included a return of spontaneous circulation and successful hospital admission. Multivariate analyses adjusted for potential confounders and within‐institution clustering effects using a generalized estimation equation were used to analyze the association of the mCPR with outcomes. Between January 1, 2012 and March 31, 2013, 6537 patients with out‐of‐hospital cardiac arrest were eligible; this included 5619 patients (86.0%) in the manual CPR group and 918 patients (14.0%) in the mCPR group. Of those patients, 28.1% (1801/6419) showed return of spontaneous circulation in the emergency department, 20.4% (1175/5754) had hospital admission, 2.6% (168/6504) survived to hospital discharge, and 1.2% (75/6419) showed a favorable neurological outcome at 1 month after admission. Multivariate analyses revealed that mCPR was associated with a decreased likelihood of survival to hospital discharge (adjusted odds ratio, 0.40; 95% confidence interval, 0.20–0.78; P=0.005), return of spontaneous circulation (adjusted odds ratio, 0.71; 95% confidence interval, 0.53–0.94; P=0.018), and hospital admission (adjusted odds ratio, 0.57; 95% confidence interval, 0.40–0.80; P=0.001).

Conclusions

After accounting for potential confounders, the mCPR in the emergency department was associated with decreased likelihoods of good clinical outcomes after adult nontraumatic out‐of‐hospital cardiac arrest. Further studies are needed to clarify circumstances in which mCPR may benefit these patients.