Survival after cardiac arrest outside hospital over a 12-year period in Gothenburg

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.

Real-Time Ventricular Fibrillation Amplitude-Spectral Area Analysis to Guide Timing of Shock Delivery Improves Defibrillation Efficacy During Cardiopulmonary Resuscitation in Swine

Background

The ventricular fibrillation amplitude spectral area (AMSA) predicts whether an electrical shock could terminate ventricular fibrillation and prompt return of spontaneous circulation. We hypothesized that AMSA can guide more precise timing for effective shock delivery during cardiopulmonary resuscitation.

Methods and Results

Three shock delivery protocols were compared in 12 pigs each after electrically induced ventricular fibrillation, with the duration of untreated ventricular fibrillation evenly stratified into 6, 9, and 12 minutes: AMSA‐Driven (AD), guided by an AMSA algorithm; Guidelines‐Driven (GD), according to cardiopulmonary resuscitation guidelines; and Guidelines‐Driven/AMSA‐Enabled (GDAE), as per GD but allowing earlier shocks upon exceeding an AMSA threshold. Shocks delivered using the AD, GD, and GDAE protocols were 21, 40, and 62, with GDAE delivering only 2 AMSA‐enabled shocks. The corresponding 240‐minute survival was 8/12, 6/12, and 2/12 (log‐rank test, P=0.035) with AD exceeding GDAE (P=0.026). The time to first shock (seconds) was (median [Q1–Q3]) 272 (161–356), 124 (124–125), and 125 (124–125) (P<0.001) with AD exceeding GD and GDAE (P<0.05); the average coronary perfusion pressure before first shock (mm Hg) was 16 (9–30), 10 (6–12), and 3 (−1 to 9) (P=0.002) with AD exceeding GDAE (P<0.05); and AMSA preceding the first shock (mV·Hz, mean±SD) was 13.3±2.2, 9.0±1.6, and 8.6±2.0 (P<0.001) with AD exceeding GD and GDAE (P<0.001). The AD protocol delivered fewer unsuccessful shocks (ie, less shock burden) yielding less postresuscitation myocardial dysfunction and higher 240‐minute survival.

Conclusions

The AD protocol improved the time precision for shock delivery, resulting in less shock burden and less postresuscitation myocardial dysfunction, potentially improving survival compared with time‐fixed, guidelines‐driven, shock delivery protocols.

Post-resuscitation care at the emergency department with critical care facilities--a length-of-stay analysis

AIM OF THE STUDY

An emergency department providing critical care will have an effect on outcome and intensive-care-units' resources by avoiding unnecessary or futile intensive-care admissions and thereby save hospital expenses. The study focussed on this result.

METHODS

The study employed a retrospective analysis of prospectively collected data of out-of-hospital cardiac arrest patients with return of spontaneous circulation, comatose on arrival. Outcomes and length of stay of patients who either stayed at the 'emergency department only' or were 'transferred in addition to an intensive care unit' were compared. Linear regression with log length of stay as outcome and 'emergency department only' as predictor with covariates was used for modelling.

RESULTS

From 1991 to 2008, out of 1236 patients (age 57 ± 15 years, female 31%), the 'emergency department only' group (n=349 (28%)) survived to discharge in 81(23%) cases, with a median length-of-stay in critical care of 1.7 (interquartile range 0.8; 3.1) days. The patients 'transferred in addition to an intensive care unit' (n=887 (72%)), with a survival rate of 55% (n=486, p<0.001) stayed 10 (5; 18) days (p<0.001). The length-of-stay in hospital was significantly shorter if patients were treated in the 'emergency department only' independent of other cardiac-arrest-related factors (regression coefficient -1.42, confidence interval -1.60 to -1.24).

CONCLUSIONS

An emergency department with critical care prevents admissions to intensive care units in 28% of patients with out-of-hospital cardiac arrest. It saves intensive-care-unit resources and shortens length of stay for comatose out-of-hospital cardiac-arrest survivors, regardless of their outcome.

Regional variation in out-of-hospital cardiac arrest incidence and outcome

CONTEXT

The health and policy implications of regional variation in incidence and outcome of out-of-hospital cardiac arrest remain to be determined.

OBJECTIVE

To evaluate whether cardiac arrest incidence and outcome differ across geographic regions.

DESIGN, SETTING, AND PATIENTS

Prospective observational study (the Resuscitation Outcomes Consortium) of all out-of-hospital cardiac arrests in 10 North American sites (8 US and 2 Canadian) from May 1, 2006, to April 30, 2007, followed up to hospital discharge, and including data available as of June 28, 2008. Cases (aged 0-108 years) were assessed by organized emergency medical services (EMS) personnel, did not have traumatic injury, and received attempts at external defibrillation or chest compressions or resuscitation was not attempted. Census data were used to determine rates adjusted for age and sex.

MAIN OUTCOME MEASURES

Incidence rate, mortality rate, case-fatality rate, and survival to discharge for patients assessed or treated by EMS personnel or with an initial rhythm of ventricular fibrillation.

RESULTS

Among the 10 sites, the total catchment population was 21.4 million, and there were 20,520 cardiac arrests. A total of 11,898 (58.0%) had resuscitation attempted; 2729 (22.9% of treated) had initial rhythm of ventricular fibrillation or ventricular tachycardia or rhythms that were shockable by an automated external defibrillator; and 954 (4.6% of total) were discharged alive. The median incidence of EMS-treated cardiac arrest across sites was 52.1 (interquartile range [IQR], 48.0-70.1) per 100,000 population; survival ranged from 3.0% to 16.3%, with a median of 8.4% (IQR, 5.4%-10.4%). Median ventricular fibrillation incidence was 12.6 (IQR, 10.6-5.2) per 100,000 population; survival ranged from 7.7% to 39.9%, with a median of 22.0% (IQR, 15.0%-24.4%), with significant differences across sites for incidence and survival (P<.001).

CONCLUSION

In this study involving 10 geographic regions in North America, there were significant and important regional differences in out-of-hospital cardiac arrest incidence and outcome.

Resuscitation by primary care doctors

BACKGROUND

Sudden cardiac arrest is a common mechanism of premature death in the community. Resuscitation is often possible, but no large study of resuscitation by doctors who practice there has been published.

METHODS

General practitioners (GPs) equipped with defibrillators reported 555 patients with cardiac arrest in whom they attempted resuscitation.

FINDINGS

Average age was 65.4, 75% male. Most arrests (49%) occurred at the patient's home but some (18%) occurred at or near the doctors' surgeries. Heart disease was responsible for 88% of the arrests: in these cases resuscitation to leave hospital alive was frequently successful (148 of 436 attempts, 34%). Success was rare (one of 59, <2%) when the arrest was due to non-cardiac disease. Resuscitation was most common when the first monitored rhythm was shockable (VF/VT) and defibrillated promptly: 144 out of 351 (41%) patients surviving. VF/VT was most common with early rhythm monitoring, particularly when the doctor was present (63% survival), or nearby (54%). When VF/VT complicated AMI, 72% of those defibrillated within 1min of onset survived. With delayed attendance, the frequency of VF/VT fell and asystole or Pulseless Electrical Activity (PEA) became more common. Survival after resuscitation was rare for patients presenting with these rhythms: five of 202 (2.5%). No such patient survived unless the rhythm could be converted to VF/VT with drugs or basic life support and subsequently shocked.

CONCLUSION

Primary care doctors equipped with defibrillators attend patients with cardiac arrest under circumstances in which resuscitation is frequently successful. This presents a unique opportunity to reduce mortality from sudden cardiac arrest.

Out-of-hospital resuscitation in Estonia: a bystander-witnessed sudden cardiac arrest

OBJECTIVE

To evaluate the results of the first epidemiological study on out-of-hospital resuscitation in Estonia.

METHODS

A prospective cohort study of 2108 consecutive standardized reports on out-of-hospital resuscitation attempts from 1 January 1999 to 31 December 2002 was conducted according to the Utstein style.

RESULTS

In all, 67.3% (1419/2108) of the cardiac arrests were of presumed cardiac aetiology and 60.2% (854/1419) of them were bystander-witnessed. Of these, the 28% bystander cardiopulmonary resuscitation was initiated, and the first rhythm was recorded as ventricular fibrillation or pulseless ventricular tachycardia in 40% of the cases. In the subgroup of patients with bystander-witnessed cardiac arrest of cardiac origin, 10.7% (91/854) were discharged alive in good cerebral performance categories and 7.7% were alive at the 1-year follow-up. The chances of survival increased if the median response time interval was <6 min, cardiac arrest occurred in a public place, patients received bystander cardiopulmonary resuscitation and had an initial rhythm of ventricular fibrillation or pulseless ventricular tachycardia. The discharge rate was 24% (82/343) in the subgroup of patients who had bystander-witnessed cardiac arrest of cardiac origin and an initial rhythm of ventricular fibrillation or pulseless ventricular tachycardia. In this subgroup, the survival rate was 42.6% (40/94) in Tartu urban area, 16.9% (22/130) in Tallinn urban area and 16.8% (20/119) in other regions of Estonia (mostly urban and suburban areas).

CONCLUSION

The results demonstrate that despite the progress in the management of out-of-hospital cardiac arrest in Estonia, only one centre (Tartu) achieves a better survival rate. Further improvements are needed to raise the quality of the Estonian emergency medical services system, especially in rural areas.

Difference in survival after out-of-hospital cardiac arrest between the two largest cities in Sweden: a matter of time?

BACKGROUND

Dramatic differences in survival after out-of-hospital cardiac arrests (OHCA) reported from different geographical locations require analysis. We therefore compared patients with OHCA in the two largest cities in Sweden with regard to various factors at resuscitation and outcome.

SETTING

All patients suffering an OHCA in Stockholm and Goteborg between 1 January 2000 and 30 June 2001, in whom cardiopulmonary resuscitation (CPR) was attempted were included in this retrospective analysis.

RESULTS

All together, 969 OHCA in Stockholm and 398 in Goteborg were registered during the 18-month study period. There were no differences in terms of age, gender, and percentage of witnessed cases or percentage of patients who had received bystander CPR. However, the percentage of patients with ventricular fibrillation (VF) at arrival of the ambulance crew was 18% in Stockholm versus 31% in Goteborg (P <0.0001). The percentage of patients who were alive 1 month after cardiac arrest was 2.5% in Stockholm versus 6.8% in Goteborg (P=0.0008). Various time intervals such as cardiac arrest to calling for an ambulance, cardiac arrest to the start of CPR and calling for an ambulance to its arrival were all significantly longer in Stockholm than in Goteborg.

CONCLUSION

Survival was almost three times higher in Goteborg than in Stockholm amongst patients suffering an OHCA. This is primarily explained by a higher occurrence of VF at the time of arrival of the ambulance crew, which in turn probably is explained by shorter delays in Goteborg. The reason for the difference in time intervals is most likely multifactorial, with a significantly higher ambulance density in Goteborg as one possible explanation.

Serial lactate determinations for prediction of outcome after cardiac arrest

We investigated the relationship between lactate clearance and outcome in patients surviving the first 48 hours after cardiac arrest. We conducted the study in the emergency department of an urban tertiary care hospital. We analyzed the data for all 48-hour survivors after successful resuscitation from cardiac arrest during a 10-year period. Serial lactate measurements, demographic data, and key cardiac arrest data were correlated to survival and best neurologic outcome within 6 months after cardiac arrest. Parameters showing significant results in univariate analysis were tested for significance in a logistic regression model. Of 1502 screened patients, 394 were analyzed. Survivors (n = 194, 49%) had lower lactate levels on admission (median, 7.8 [interquartile range, 5.4-10.8] vs 9 [6.6-11.9] mmol/L), after 24 hours (1.4 [1-2.5] vs 1.7 [1.1-3] mmol/L), and after 48 hours (1.2 [0.9-1.6] vs 1.5 [1.1-2.3] mmol/L). Patients with favorable neurologic outcome (n = 186, 47%) showed lower levels on admission (7.6 [5.4-10.3] vs 9.2 [6.7-12.1] mmol/L) and after 48 hours (1.2 [0.9-1.6] vs 1.5 [1-2.2] mmol/L). In multivariate analysis, lactate levels at 48 hours were an independent predictor for mortality (odds ratio [OR]: 1.49 increase per mmol/L, 95% confidence interval [CI]: 1.17-1.89) and unfavorable neurologic outcome (OR: 1.28 increase per mmol/L, 95% CI: 1.08-1.51). Lactate levels higher than 2 mmol/L after 48 hours predicted mortality with a specificity of 86% and poor neurologic outcome with a specificity of 87%. Sensitivity for both end points was 31%. Lactate at 48 hours after cardiac arrest is an independent predictor of mortality and unfavorable neurologic outcome. Persisting hyperlactatemia over 48 hours predicts a poor prognosis.

Decrease in the occurrence of ventricular fibrillation as the initially observed arrhythmia after out-of-hospital cardiac arrest during 11 years in Sweden

AIM

To describe the change in the occurrence of ventricular fibrillation as initially observed arrhythmia among patients suffering from out-of-hospital cardiac arrest in Sweden.

PATIENTS

All patients included in the Swedish cardiac arrest registry between 1991 until 2001. The registry covers 85% of the population in Sweden.

METHODS

All patients with bystander witnessed out-of-hospital cardiac arrest included in the Swedish Cardiac Arrest Registry between 1991 and 2001 from the same ambulance organisation each year were included in the survey.

RESULTS

Over 11 years, among patients in Sweden with a bystander witnessed out-of-hospital cardiac arrest in whom cardiopulmonary resuscitation (CPR) was attempted (n = 9666), the occurrence of ventricular fibrillation as the initially obseved arrhythmia decreased from 45% in 1991 to 28% in 2001 (P < 0.0001) if the arrest occurred at home, and from 57% to 41% if the arrest occurred outside home (P < 0.0001). This was found despite the fact that the proportion who received bystander CPR increased from 29% in 1991 to 39% in 2001 if the arrest occurred at home (P < 0.0001) and from 54% to 60% if the arrest occurred outside home (NS). There was a significant increase in age among patients with out-of-hospital cardiac arrest at home, no change in the estimated interval between collapse and call but an increase in the interval between call and arrival of the ambulance among patients with out-of-hospital cardiac arrest outside home.

CONCLUSION

During 11 years in Sweden, there was a marked decrease in the proportion of patients found in ventricular fibrillation among patients with a bystander witnessed cardiac arrest regardless whether the arrest occurred at home or outside home. A modest increase in age and interval between call for, and arrival of, the ambulance was associated with these findings.

Optimal timing for electrical defibrillation after prolonged untreated ventricular fibrillation

OBJECTIVE

It currently is recommended that electrical shocks be delivered immediately on recognition of ventricular fibrillation. However, decreased effectiveness of this approach has been reported after prolonged intervals of untreated ventricular fibrillation. We investigated the optimal strategy for successful defibrillation after prolonged untreated ventricular fibrillation by using a rat model of ventricular fibrillation and closed-chest resuscitation.

DESIGN

Controlled, randomized, laboratory study.

SETTING

Research laboratory at a VA hospital.

SUBJECTS

Seventy pentobarbital anesthetized Sprague-Dawley rats.

INTERVENTIONS

After 10 mins of untreated ventricular fibrillation, four groups of rats were randomized to receive electrical shocks (which we designated as "experimental shocks") immediately before or at 2, 4, or 6 mins of chest compression. Unsuccessfully defibrillated rats received additional shocks (which we designated as "rescue shocks") after 8 mins of chest compression.

MEASUREMENTS AND MAIN RESULTS

The number of rats that restored spontaneous circulation after the experimental shocks increased with increasing duration of the predefibrillatory interval of chest compression (0 of 8, 0 of 8, 2 of 8, and 7 of 8, respectively, p <.005). Two additional groups then were randomized to receive repetitive experimental shocks at 2, 4, and 6 mins or a single attempt at 6 mins of chest compression. Although a comparable number of rats restored spontaneous circulation in each group, rats subjected to repetitive defibrillation attempts had more intense postresuscitation ectopic activity and worse survival. Two final groups were used to investigate whether inhibition of the sarcolemmal sodium-hydrogen exchanger isoform-1 (NHE-1) could facilitate return of spontaneous circulation during repetitive defibrillation attempts. Although spontaneous circulation was restored earlier in more rats subjected to NHE-1 inhibition, the differences were statistically insignificant. NHE-1 inhibition, however, replicated previously reported resuscitation and postresuscitation benefits. The optimal predefibrillation interval of chest compression was approximately 6 mins, and this coincided with partial return of the amplitude and frequency characteristics of the ventricular fibrillation waveform to those present immediately after induction of ventricular fibrillation.

CONCLUSIONS

Improved outcome after prolonged untreated ventricular fibrillation may result from strategies that provide chest compression before attempting defibrillation and avoid early and repetitive defibrillation attempts. The amplitude and frequency characteristics of the ventricular fibrillation waveform could help identify the optimal timing for attempting electrical defibrillation.

Interaction between emergency medical dispatcher and caller in suspected out-of-hospital cardiac arrest calls with focus on agonal breathing. A review of 100 tape recordings of true cardiac arrest cases

AIM

One of the objectives of this study was to assess the emergency medical dispatchers (EMDs) ability for the identification and prioritisation of cardiac arrest (CA) cases, and offering and achievements of dispatcher-assisted bystander cardiopulmonary resuscitation (CPR). The other objective was to give an account of the frequency of agonal respiration in cardiac arrest calls and the caller's descriptions of breathing.

METHODS

Prospective study evaluating 100 tape recordings of the EMD calls of emergency medical service (EMS)-provided advanced life support- (ALS) cases, of out-of-hospital cardiac arrest.

RESULTS

The quality of EMD-performed interviews was highly commended in 63% of cases, but insufficient or unapproved in the remaining 37%. The caller's state of mind was not a major problem for co-operation. Among the 100 cases, 24 were suspected to be unconscious and in respiratory arrest. A further 38 cases were presented as unconscious with abnormal breathing. In only 14 cases dispatcher-assisted bystander CPR was offered by the EMD, and in 11 of these it was attempted, and completed in eight. Only four of the cases were unconscious patients with abnormal breathing. The incidence of suspected agonal breathing was estimated to be approximately 30% and the descriptions were; difficulty, poorly, gasping, wheezing, impaired, occasional breathing.

CONCLUSIONS

Among suspected cardiac arrest cases, EMDs offer CPR instruction to only a small fraction of callers. A major obstacle was the presentation of agonal breathing. Patients with a combination of unconsciousness and agonal breathing should be offered dispatcher-assisted CPR instruction. This might improve survival in out-of hospital cardiac arrest.

High survival in out-of-hospital cardiopulmonary resuscitation--7 years' incidence according to the Utstein template in a small town in Northern Norway

Core data according to the Utstein template was compiled from all out-of-hospital resuscitations in the city of Bodø, Northern Norway, over 7 years (1992-98). Out of a population of 34,500, 149 resuscitations were attempted. A cardiac aetiology was present in 123 patients and their median age was 72.1 years. Eighteen of the 96 patients having suffered a witnessed arrest of cardiac origin were alive after 1 year (18.8%). Fifteen had the best cerebral performance score (scale 1-5) and three had a score of 2. Survival among all resuscitated patients (149) was 18.8% also, giving a number of 62 attempted resuscitations and 11.2 survivors per 100,000 inhabitants per year, respectively. Thirty-three per cent of witnessed cardiac arrests with ventricular fibrillation or ventricular tachycardia survived to discharge, but only 7% with asystole. When the arrest was witnessed, median response time was 5 minutes, and was 3 minutes for the survivors. To our knowledge, this is the highest survival of out-of-hospital arrests in Scandinavia reported so far, and is chiefly explained by short turnout distances.

Factors affecting short- and long-term prognosis among 1069 patients with out-of-hospital cardiac arrest and pulseless electrical activity

AIMS

To describe the epidemiology, resuscitation factors and prognosis among a consecutive population of patients suffering from out-of-hospital cardiac arrest (OHCA) where pulseless electrical activity (PEA) was the first arrhythmia recorded on emergency medical services (EMS) arrival.

METHODS

Analysis of data collected prospectively on all patients regardless of age succumbing to OHCA during 1980-1997 in the community of Gothenburg where EMS initiated resuscitative measures.

RESULTS

4662 patients with OHCA were attended by the EMS during the study period. Of these, 1069 (23%) were judged as having PEA as the first recorded arrhythmia; 158 (15%) of these were admitted alive to hospital and 26 (2.4%) were discharged alive. Survivors to discharge had a significantly larger share of bystander cardiopulmonary resuscitation (CPR) (28 vs. 8%, P=0.008), significantly higher levels of consciousness (8% awake vs. 0%, P<0.001) and higher median systolic blood pressure (145 vs. 106 mmHg, P<0.001) on arrival at hospital. No patient with unwitnessed cardiac arrest and PEA over 80 years old survived.

CONCLUSION

Survival among patients suffering from OHCA and PEA is poor, especially among the elderly unwitnessed cases and those who do not receive bystander CPR. The latter seems to be of utmost importance among these patients.

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

OBJECTIVE

To study the outcome from prehospital cardiac arrest managed by ambulance personnel, and to examine overall survival rates from successful resuscitation.

METHODS

A retrospective analysis was made of 115 patient care records of prehospital cardiac arrests with attempted resuscitation between July 1996 and September 1999. All cases had a presumed primary cardiac cause for their cardiac arrest.

RESULTS

Overall survival, defined as admitted to hospital alive, was 22 subjects (19.1%), with five subjects (4.3%) being discharged from hospital neurologically intact. Of the patients who survived to the emergency department, six (5%) had initially presented in pulseless electrical activity and 16 (14%) presented with ventricular fibrillation. No patients presented with ventricular tachycardia and no survivors presented in asystole. Median response interval from time of call to arrival of initial crew at patient's side was 9 min. No patients survived when response interval was greater than 14 min. Bystander cardiopulmonary resuscitation was being performed on 55 patients (48%) on arrival of initial ambulance crew; 68.2% of patients surviving to hospital having had bystander cardiopulmonary resuscitation.

CONCLUSION

Decreasing time delays in accessing the patient is crucial to improving outcome in out-of-hospital cardiac arrest.

Estimating the effect of bystander-initiated cardiopulmonary resuscitation in Japan

Low incidence of bystander-initiated cardiopulmonary resuscitation (CPR) is allegedly responsible for poor survival from out-of-hospital cardiac arrest (OHCA) in Japan. This study was conducted to determine significant predictors for survival after collapse-witnessed OHCA of presumed cardiac etiology to investigate the impact of bystander-initiated CPR. Logistic regression analysis of OHCA of presumed cardiac etiology was performed on retrospective data sets from three Japanese suburban communities. All arrest incidents were witnessed and occurred prior to the arrival of EMS personnel. Outcome measure was survival to discharge. Initial electrocardiogram (ECG) rhythm (ventricular fibrillation (VF) or not), interval from collapse to CPR (within 5 min or not), and initial ECG rhythm/collapse-to-CPR interval interaction were significantly associated with survival. Patient age (70 years or less/over 70 years), interval from collapse to EMS response, and bystander-initiated CPR were significantly associated with VF in an initial ECG. The effectiveness of bystander-initiated CPR for OHCA can be successfully predicted based on the interval from collapse to CPR and initial ECG rhythm. The increase in the proportion of bystander-initiated CPR from the present level of 20-50% would be expected to rescue another 1800 victims of OHCA per year in Japan.

Characteristics and outcome among patients suffering in-hospital cardiac arrest in monitored and non-monitored areas

AIM

To describe the characteristics and outcome among patients suffering in-hospital cardiac arrest in relation to whether the arrest took place in a ward with monitoring facilities.

METHODS

All patients who suffered an in-hospital cardiac arrest during a 4-year period in Sahlgrenska Hospital, Göteborg, Sweden and in whom resuscitative efforts were attempted, were prospectively recorded and described in terms of characteristics and outcome.

RESULTS

Among 557 patients, 292 (53%) had a cardiac arrest in wards with monitoring facilities. Those in a monitored location more frequently had a confirmed or possible acute myocardial infarction (AMI) as judged to be the cause of arrest (P < 0.0001), and the arrest was witnessed more frequently (96 vs. 79%; P < 0.0001). Ventricular fibrillation/tachycardia was observed more often as initial arrhythmia in monitored wards (56 vs. 44%; P = 0.006). The median interval between collapse and first defibrillation was 1 min in monitored wards and 5 min in non-monitored wards (P < 0.0001). Among patients with arrest in monitored wards 43.2% were discharged alive compared with 31.1% of patients in non-monitored wards (P = 0.004). Cerebral performance category (CPC-score) at discharge was somewhat better among survivors in monitored wards.

CONCLUSION

In a Swedish University Hospital 47% of in-hospital cardiac arrests in which resuscitation was attempted took place in wards without monitoring facilities. These patients differed markedly from those having arrest in wards with monitoring facilities in terms of characteristics, interval to defibrillation and outcome. A shortening of the interval between collapse and defibrillation in these patients might increase survival even further.

Successful out-of-hospital cardiopulmonary resuscitation: what is the optimal in-hospital treatment strategy?

The aim of the study was to evaluate prognostic factors in patients after successful out-of-hospital resuscitation (sOHR) within 30 min after admission. A prognostic scoring scale in patients surviving OHR was analysed. We also studied the effect of these predictive factors and the in-hospital treatment (percutaneous transluminal coronary angioplasty (PTCA) vs. thrombolysis) on mortality. We performed a retrospective analysis of the emergency medical system forms and medical files of 72 consecutive patients aged > or =18 years with sOHR. Of these 72 patients 37 (51%) met the electrocardiographic and enzymatic criteria for acute myocardial infarction (AMI). Ten of the 37 AMI patients (27%) underwent acute PTCA as primary treatment and seven patients (19%) received thrombolytic therapy for AMI despite prolonged (mean 24+/-13 min) cardiopulmonary resuscitation (CPR). The remaining 20 patients had no specific infarct treatment. Despite successful PTCA, in eight out of ten patients, their mortality in hospital was 60% (6/10). Mortality in the thrombolysis group was 57% (4/7). For the remaining 20 MI-patients the mortality was 65% (13/20). Univariate and multivariate analyses were performed to design a weighted prognostic scoring system. The Glasgow coma scale (GCS) was the strongest independent predictor (r=0.76, P< or =0.001) for in-hospital death.

CONCLUSIONS

in-hospital mortality after successful OHR seems to largely depend on neurological status at admission and much less on the specific treatment of myocardial infarction. The prognostic scoring system accurately predicted the in-hospital mortality and can be used for early treatment stratification; however, it should be proven in a prospective study.

The attitudes of cardiac arrest survivors and their family members towards CPR courses

OBJECTIVES

to evaluate self-assessment of first aid knowledge, readiness to make use of it in case of a medical emergency and judgement of a 1-day CPR course by cardiac arrest survivors, their family members and friends as compared to the general public.

BACKGROUND

the recurrence rate of a cardiac arrest after successful resuscitation is high and most of out-of-hospital cardiac arrests occur at the patient's home.

METHODS

medical students trained in basic and advanced life support provided 101 members of the target group and 94 of a sex and age matched control group with a 1-day course in CPR.

RESULTS

after the course, half of the participants in both groups considered their knowledge of first aid to be very good or good. The readiness to perform first aid in a medical emergency increased significantly. Of the target group 96% of the participants as compared with the control group where 91% felt confident to recognise a cardiac arrest; 79 versus 68% considered themselves capable to perform CPR if needed. The course was judged as very good in 71 versus 69% and as good in 25 versus 27% with no differences between groups.

CONCLUSION

one-day CPR courses are well accepted by cardiac arrest survivors, their family members and friends and help to reduce fears of reacting in medical emergencies. They seem to be more motivated to gain and use first aid knowledge than others.

Can we define patients with no and those with some chance of survival when found in asystole out of hospital?

We describe the epidemiology, prognosis, and circumstances at resuscitation among a consecutive population of patients with out-of-hospital cardiac arrest (OHCA) with asystole as the arrhythmia first recorded by the Emergency Medical Service (EMS), and identify factors associated with survival. We included all patients in the municipality of Göteborg, regardless of age and etiology, who experienced an OHCA between 1981 and 1997. There were a total of 4,662 cardiac arrests attended by the EMS during the study period. Of these, 1,635 (35%) were judged as having asystole as the first-recorded arrhythmia: 156 of these patients (10%) were admitted alive to hospital, and 32 (2%) were discharged alive. Survivors were younger (median age 58 vs 68 years) and had a witnessed cardiac arrest more often than nonsurvivors (78% vs 50%). Survivors also had shorter intervals from collapse to arrival of ambulance (3.5 vs 6 minutes) and the mobile coronary care unit (MCCU) (5 vs 10 min), and they received atropine less often on scene. There were also a greater proportion of survivors with noncardiac etiologies of cardiac arrest (48% vs 27%). Survivors to discharge also displayed higher degrees of consciousness on arrival to the emergency department in comparison to nonsurvivors. Multivariate analysis among all patients with asystole indicated age (p = 0.01) and witnessed arrest (p = 0.03) as independent predictors of an increased chance of survival. Multivariate analysis among witnessed arrests indicated short time to arrival of the MCCU (p < 0.001) and no treatment with atropine (p = 0.05) as independent predictors of survival. Fifty-five percent of patients discharged alive had none or small neurologic deficits (cerebral performance categories 1 or 2). No patients > 70 years old with unwitnessed arrests (n = 211) survived to discharge.

A comparison between patients suffering in-hospital and out-of-hospital cardiac arrest in terms of treatment and outcome

AIM

To compare treatment and outcome amongst patients suffering in-hospital and out-of-hospital cardiac arrest in the same community.

PATIENTS

All patients suffering in-hospital cardiac arrest in Sahlgrenska University Hospital covering half the catchment area of the community of Göteborg (500 000 inhabitants) and all patients suffering out-of-hospital cardiac arrest in the community of Göteborg. Criteria for inclusion were that resuscitation efforts should have been attempted. TIME OF SURVEY: From 1 November 1994 to 1 November 1997.

METHODS

Data were recorded both prospectively and retrospectively.

RESULTS

In total, 422 patients suffered in-hospital cardiac arrest and 778 patients suffered out-of-hospital cardiac arrest. Patients with in-hospital cardiac arrest included more women and were more frequently found in ventricular fibrillation. The median interval between collapse and defibrillation was 2 min in in-hospital cardiac arrest compared with 7 min in out-of-hospital cardiac arrest (< 0.001). The proportion of patients being discharged from hospital was 37.5% after in-hospital cardiac arrest, compared with 8.7% after out-of-hospital cardiac arrest (P < 0.001). Corresponding figures for patients found in ventricular fibrillation were 56.9 vs. 19.7% (P < 0.001) and for patients found in asystole 25.2 vs. 1.8% (P < 0.001).

CONCLUSION

In a survey evaluating patients with in-hospital and out-of-hospital cardiac arrest in whom resuscitation efforts were attempted, we found that the former group had a survival rate more than four times higher than the latter. Possible strong contributing factors to this observation are: (i) shorter time interval to start of treatment, and (ii) a prepared selection for resuscitation efforts.

Recent progress in advanced cardiac life support

The revised guidelines for advanced cardiac life support (ACLS) from the American Heart Association are anticipated in the fall of 2000. Although dramatic changes in the approach to adult basic and ACLS are not anticipated, several controversies and new drugs on the horizon may radically change our approach to emergent cardiac resuscitation. This article features some of the evolving thinking on the emergent treatment of the adult with ventricular fibrillation or ventricular tachycardia, the critical rhythms seen in most cases of acute cardiac distress. Approaches to airway therapy drug administration and new agents also are described.

Possibilities of implementing dispatcher-assisted cardiopulmonary resuscitation in the community. An evaluation of 99 consecutive out-of-hospital cardiac arrests

AIM

By evaluating tape recordings of true cardiac arrest calls, to judge the dispatchers ability to (a) identify cases as suspected cardiac arrest (CA), (b) give the case the right priority, (c) identify CA cases suitable for dispatcher-assisted, telephone-guided cardiopulmonary resuscitation (T-CPR) and (d) accomplish T-CPR.

METHODS

Evaluation of 99 tape recordings of consecutive cases that had been admitted to the two city hospitals in Göteborg after out-of-hospital CA.

RESULTS

In 70% of the interviews, the dispatcher demonstrated impeccable behaviour with short, distinct questions, quickly resulting in a decision on how to handle the case. In 30%, serious criticism could be voiced as the dispatcher displayed very stressful behaviour, or omitted to ask important questions such as whether the patient was conscious and breathing. In 21%, the interviews indicated a clear opportunity to perform T-CPR. In another 10%, there was a possibility of performing T-CPR. Only in 8% was T-CPR actually accomplished.

CONCLUSIONS

(1) In the majority of the interviews, the quality was very high, while in one-third, serious criticism could be voiced. (2) In our study, only one-third (95% confidence interval, 22-41) of CA cases were suitable for T-CPR, and T-CPR was performed in only 8% of the 99 cases. (3) To optimise the dispatcher ability to identify suspected CA and initiate T-CPR, both medical knowledge and practical training are needed, preferably with protocols for pre-arrival instructions.

Incidence, duration and survival of ventricular fibrillation in out-of-hospital cardiac arrest patients in sweden

The chance of survival from ventricular fibrillation (VF) is up to ten times higher than those with other cardiac arrest rhythms. To calculate the effect of out-of-hospital resuscitation organisations on survival, it is necessary to know the percentage of cardiac arrest patients initially in VF and the relationship between delay time to defibrillation and survival.

AIM

To study the incidence of VF at the time of cardiac arrest and on first ECG, the duration of VF and the relation between time to defibrillation and survival.

METHOD

The Swedish Cardiac Arrest Registry has collected standardised reports on out-of-hospital cardiac arrests from ambulance organisations in Sweden, serving 60% of the Swedish population.

RESULTS

In 14065 cases of out-of-hospital cardiac arrest collected between 1990 and 1995, resuscitation was attempted in 10966 cases.

INCIDENCE

The first ECG showed VF in 43% of all patients. The incidence of VF at the time of cardiac arrest was estimated to be 60-70% in all patients and 80-85% in the cases with probable heart disease.

DURATION

The estimated disappearance rate of VF was slow. Thirty minutes after collapse approximately 40% of the patients were in VF.

SURVIVAL

Overall survival to 1 month was only 1.6% for patients with non-shockable rhythms and 9.5% for patients found in VF. With increasing time to defibrillation, the survival rate fell rapidly from approximately 50% with a minimal delay to 5% at 15 min.

CONCLUSIONS

This study suggests a high initial incidence of VF among out-of-hospital cardiac arrest patients and a slow rate of transformation into a non-shockable rhythm. The survival rate with very short delay times to defibrillation was approximately 50%, but decreased rapidly as the delay increased.

Out-of-hospital cardiac arrest in north-east Germany: increased resuscitation efforts and improved survival

In the years after 1989 major political and socioeconomic changes have taken place in East Germany. In parallel, emergency medical services (EMS) were restructured according to western standards. In Stralsund the EMS was restructured from a single to a two tier system with implementation of a second ambulance base in 1990. The number of household telephone extensions more than doubled. To analyze the effects of these changes, patients receiving advanced life support (ALS) for out-of-hospital cardiac arrest of cardiac origin (OHCA) between 1984 and 1988, and from 1991 to 1997 were studied. Adjusted per 100,000 inhabitants, the number of OHCA patients receiving ALS increased from 11 per year before 1989 to 52 per year after 1990 (P < 0.01). Survival without relevant neurologic defects was achieved in 3.7% (2/53) of patients before 1989 and in 8.1% (22/273) after 1990. Response time of the ALS unit shortened from 11.0 +/- 1.4 to 9.0 +/- 0.4 min (n.s.), while response time of any EMS shortened from 11.0 +/- 1.4 to 6.1 +/- 0.3 min (P < 0.005). Adjusted for observation period and population served, there was a 10-fold increase in the number of resuscitations attempted at home and an 8-fold increase in the absolute number of OHCA survivors without relevant neurological defects. In parallel to socioeconomic changes, the restructuring of the EMS in Stralsund and the rapid expansion of the telephone network led to a significant increase in the number of patients successfully resuscitated from OHCA. If the present results can be transferred to other former socialist countries of East and Middle Europe, they may have important implications for the EMS in these regions.

Cardiac arrest in Saudi Arabia: a 7-year experience in Riyadh

All out-of-hospital and Emergency Department (ED) cardiac arrests treated at a tertiary care hospital in Riyadh, Saudi Arabia, from 1989 through 1995 were studied. Of patients arresting out-of-hospital, 3.0% received bystander cardiopulmonary resuscitation (CPR), 9.1% had some prehospital CPR, 12.1% were transported via ambulance, and 13.6% had ventricular fibrillation (VF) on ED arrival. In the witnessed arrests (80%), the estimated interval from arrest to initiation of CPR was 21.1 +/- 14.7 min. None of these variables was shown to influence outcome. Survival to hospital discharge from out-of-hospital arrest was 5.1% for adults and 7.4% for children; all had poor neurologic outcome. For patients arresting in the ED, an initial rhythm of ventricular tachycardia (VT) or VF was strongly correlated with survival. Survival from ED arrest was 30.4% in adults, 42.9% in children; all but one had normal neurologic outcome. These results are similar to those reported from large cities and EDs elsewhere. The unique set of variables influencing out-of-hospital care and transportation in Riyadh are discussed, and potential areas for improvement are noted.

Resuscitation in Europe: a tale of five European regions

AIM

To describe cardiac arrest data from five emergency medical services (EMS) systems in Europe with regard to survival from an out-of-hospital cardiac arrest.

METHODS

Based on recommendations from various countries in Europe EMS systems were approached with regard to survival from out-of-hospital cardiac arrest. Five EMS systems were asked to report their cardiac arrest data according to the Utstein style.

RESULTS

The five selected EMS systems were: Bonn (Germany), Göttingen (Germany), Helsinki (Finland), Reykjavik (Iceland) and Stavanger (Norway). For patients with a bystander witnessed arrest of cardiac aetiology the percentage of patients being discharged alive from hospital in these regions were: 21, 33, 23, 23 and 35. The corresponding percentages for patients fulfilling criteria as above and being found in ventricular fibrillation were: 32, 42, 32, 27 and 55.

CONCLUSIONS

Many EMS systems in Europe show extremely good results in terms of survival after an out-of-hospital cardiac arrest. Some of the results should be interpreted with caution since they were based on relatively small sample sizes. Furthermore, the results from one of the regions (Stavanger) was unit based and not community based.

There is a difference in characteristics and outcome between women and men who suffer out of hospital cardiac arrest

OBJECTIVE

To evaluate whether there is a difference in characteristics and outcome in relation to gender among patients who suffer out of hospital cardiac arrest.

DESIGN

Observational study.

SETTING

The community of Göteborg.

PATIENTS

All patients in the community of Göteborg who suffered out of hospital cardiac arrest between 1980 and 1996, and in whom cardiopulmonary resuscitation (CPR) was initiated.

MAIN OUTCOME MEASURES

Factors at resuscitation and the proportion of patients being hospitalized and discharged from hospital. P values were corrected for age.

RESULTS

The women were older than the men (median of 73 vs. 69 years; P < 0.0001), they received bystander-CPR less frequently (11 vs. 15%; P = 0.003), they were found in ongoing ventricular fibrillation less frequently (28 vs. 44%; P < 0.0001), and their arrests were judged to be of cardiac origin less frequently. In a multivariate analysis considering age, gender, arrest being due to a cardiac etiology, initial arrhythmia and by-stander initiated CPR, female gender appeared as an independent predictor for patients being brought to hospital alive (odds ratio 1.37; P = 0.001) but not for patients being discharged from hospital.

CONCLUSION

Among patients who suffer out of hospital cardiac arrest with attempted CPR women differ from men being older, receive bystander CPR less frequently, have a cardiac etiology less frequently and are found in ventricular fibrillation less frequently. Finally female gender is associated with an increased chance of arriving at hospital alive.

Relative importance of improved hospital treatment and primary prevention. Results from 20 years of the Myocardial Infarction Register, Göteborg, Sweden

OBJECTIVE

To analyse to what extent declines in incidence and mortality of coronary artery disease can be attributed to improved hospital and post-hospital treatment in contrast to how much is due to primary prevention.

DESIGN

A register for non-fatal and fatal myocardial infarction and sudden coronary death registered in in-hospital as well as out-of-hospital events between 1975 and 1994.

SETTING

City of Göteborg, Sweden, with 450,000 inhabitants.

RESULTS

Seventy-one per cent of the decline in attacks could be attributed to a decline in first infarctions. Of the decrease in coronary deaths, 63% was due to a decline in out-of-hospital mortality. Previous registrations for myocardial infarction were considerably more common amongst people who died in hospital (29%) than amongst those who died out-of-hospital (11-16%) or who survived an infarction (11-13%). Out-of-hospital resuscitation contributed to about half of the reduction in out-of-hospital mortality. Thus, most of the decline in incidence and about half of the decline in sudden coronary deaths was due to primary preventive measures. Population data on risk factors indicate a decline of 37% between 1963 and 1995 in coronary risk amongst consecutive cohorts of 50-year-old men in the community.

CONCLUSION

Out-of-hospital resuscitation, treatment in coronary care units and post-infarct treatment improved considerably, but changes in primary risk factors were also of major importance for the decline in incidence and mortality.

As seen on TV: observational study of cardiopulmonary resuscitation in British television medical dramas

OBJECTIVE

To determine the frequency and accuracy with which cardiopulmonary resuscitation is portrayed in British television medical dramas.

DESIGN

Observational study.

SUBJECTS

64 episodes of three major British television medical dramas: Casualty, Cardiac Arrest, and Medics.

MAIN OUTCOME MEASURES

Frequency of cardiopulmonary resuscitation shown on television; age, sex, and diagnosis of the patients undergoing resuscitation; rate of survival through resuscitation.

RESULTS

Overall 52 patients had a cardiorespiratory arrest on screen and 3 had a respiratory arrest alone, all the arrests occurring in 40 of the 64 episodes. Of the 52 patients having cardiorespiratory arrest, 32 (62%) underwent an attempt at cardiopulmonary resuscitation; 8 attempts were successful. All 3 of the patients having respiratory arrests alone received ventilatory support and survived. On 48% of occasions, victims of cardiac arrest seemed to be less than 35 years old.

CONCLUSIONS

Cardiorespiratory resuscitation is often depicted in British television medical dramas. Patients portrayed receiving resuscitation are likely to be in a younger age group than in real life. Though the reasons for resuscitation are more varied and more often associated with trauma than in reality, the overall success rate is nevertheless realistic. Widespread overoptimism of patients for survival after resuscitation cannot necessarily be blamed on British television medical dramas.

Experience with the use of automated external defibrillators in out of hospital cardiac arrest

AIM

To describe the sequences of arrhythmias, number of shocks delivered and the number of failures in a consecutive series of patients with out-of-hospital cardiac arrest attended by our emergency medical service (EMS) and in whom cardio-pulmonary resuscitation (CPR) was initiated and in whom automated external defibrillators (AEDs) were used.

PATIENTS

All patients with out-of-hospital cardiac arrest attended by the EMS and in whom AEDs were used. Time for inclusion in the study: January 1st, 1987 to December 31st, 1992.

RESULTS

In all there were 1781 out of hospital cardiac arrests during the study period. Among them AEDs were used in 383 cases (22%). The total number of interpreted rhythms delivered in these patients was 2719. Among all rhythm sequences coarse ventricular fibrillation (VF) was found on 375 occasions (14%); fine VF on 107 occasions (4%) and ventricular tachycardia (VT) on 12 occasions (0.4%). In ten cases with coarse VF (nine patients) the AED did not advise a shock (2.7%). In five of those nine patients a human error was interpreted as the explanation and in four there was a possible technical error. In these four patients defibrillation was delayed by 33-43 s, respectively. Among the 2225 rhythm sequences not judged as VF/VT the AED advised a shock on one occasion (0.04%).

CONCLUSION

Among patients with coarse VF AED gave inaccurate instructions in 2.7%. However, the majority of the failures were judged to be caused by human errors.

Factors surrounding cardiopulmonary resuscitation influencing bystanders' psychological reactions

The incidence of Sweden's out-of-hospital cardiac arrests averages 10000 annually. Each year bystanders initiate cardiopulmonary resuscitation (CPR) approximately 2000 times prior to arrival of emergency medical service (EMS). The aim of this study was to identify factors influencing the bystanders psychological reactions to performing CPR. We mailed a questionnaire to all bystanders who reported performing CPR to the CPR Centre of Sweden from autumn 1992 to 1995. The study included 544 bystander reports. Nine factors were found to be associated with bystanders experience in a univariate analysis. Among these were victim outcome (p < 0.0001), CPR duration (p = 0.0009) and their experience of the attitude of the EMS personnel (p = 0.004). In a multivariate logistic regression model, lack of debriefing following the intervention (p = 0.0001) and fatal victim outcome (p = 0.03) were independent predictors of a negative bystander psychological reaction. The importance of having someone to talk to following an intervention and the EMS personnel concern for the rescuer should be emphasised. The goal should be that critical incident debriefing is available to every bystander following his or her CPR attempt.

Epidemiology and survival rate of out-of-hospital cardiac arrest in north-east Italy: The F.A.C.S. study. Friuli Venezia Giulia Cardiac Arrest Cooperative Study

The results of the first epidemiological, prospective, multicentric study on cardiac arrest in a geographical Italian region are reported. On 708 consecutive cardiac arrests, 438 underwent cardiopulmonary resuscitation (CPR). Of these, 344 were identified of cardiac aetiology. The underlying initial rhythm was: 166 asystole (48.3%), 104 ventricular fibrillation (30.2%), 74 pulseless electrical activity (21.5%). The best outcome occurred in patients whose cardiac arrest was witnessed by the EMS (49% return of spontaneous circulation (ROSC), 21% hospital discharge). When cardiac arrest was witnessed by lay people, 20.5% had ROSC and 4.4% were discharged alive from the hospital. When it was unwitnessed ROSC and hospital discharge were 8.6 and 1.7%, respectively. Ventricular fibrillation was highly predictive of outcome. Both ROSC and hospital discharge correlated inversely with the delay of the first defibrillation. Overall, the highest probability of survival was achieved when CPR interventions were started within the first minutes after collapse. Basic Life Support (BLS) manoeuvres began after 9 min of untreated cardiac arrest were still followed by a ROSC, but none of these patients survived. The incidence of prehospital cardiac arrest in our population was estimated to be in proportion of 0.95/1000 per year with a survival rate of 6.7%.

Survival after cardiac arrest outside hospital in Sweden. Swedish Cardiac Arrest Registry

The voluntary Swedish Cardiac Arrest Registry has collected and analyzed 14,065 standardised reports on cardiac arrests up until May 1995. The reports have been collected from approximately half of Sweden's ambulance districts, which cover 60% of the population. Resuscitation was attempted in 10,966 cases. The median age was 70 years. In 70.0% the arrest was witnessed, and in 43.3% the first recorded rhythm was VT/VF. Bystander-CPR was initiated in 32.3% of the cases. Most cardiac arrests took place at home (65.8%) and 67.1% were judged to be of cardiac origin. In 1692 cases (15.4%), the patient was admitted alive in hospital and 544 patients (5.0%) were alive after 1 month. Survival to 1 month in the subgroup which presented with VT/VF was 9.5%. We found no significant difference between survival in large cities and smaller communities. The survivors were analysed in relation to time to defibrillation and we found a strong correlation between a short time and increased survival.

Survivors of out of hospital cardiac arrest: their prognosis, longevity and functional status

This paper reports, consistent with Utstein Style definitions, 13 years experience observing out-of-hospital cardiac arrest survivors' prognosis, longevity and functional status. We report for all patients, available outcome information for out-of-hospital cardiac arrest survivors in Göteborg Sweden between 1980 and 1993. Patients were followed for at least 1 year and some for over 14 years. From 1980 to 1993 Göteborg EMS treated 3754 out-of-hospital cardiac arrests. 9% (n = 324) were discharged from the hospital alive. Survivors' median age was 67 and 21% (n = 67) were women. Mortality rate was: 21% (n = 61) at 1 year; 56% (n = 78) by 5 years; and 82% (n = 32) by 10 years following the arrest. During the first 3 years, 16% (n = 46) experienced another cardiac arrest, 19% (n = 53) had an acute myocardial infraction and a total of 81% (n = 232) were rehospitalized for various conditions. 14% (n = 40) returned to previous employment, and 74% (n = 229) had retired before their arrest occurred. Cerebral performance categories (CPC) scores were: At hospital discharge N = 324; Data available for 320-1 = 53% (n = 171), 2 = 21% (n = 66), 3 = 24% (n = 77), 4 = 2% (n = 6). One year post arrest N = 263; Data available for 212-1 = 73% (n = 156), 2 = 9% (n = 18), 3 = 17% (n = 36), 4 = 1% (n = 2). Overall, 21% (n = 61) of cardiac arrest survivors died during the first year, and an additional 16% (n = 46) experienced another arrest. 73% of those patients who were still alive after 1 year returned to pre-arrest function.

Outcome of out-of-hospital cardiorespiratory arrest in south Glamorgan

During 138 weeks an emergency medical service (EMS) of mixed skill-level attempted to resuscitate 954 patients from prehospital cardiac arrest (883 attempts per million population per year); 75% of the arrests were of cardiac cause. This paper is one of the first analyses from europe to use the 'Utstein template' to report outcomes of such arrests. In cases where an arrest rhythm could be recorded, 38.4% were ventricular fibrillation (VF), 45.5% were asystolic, and the remainder were either electromechanical dissociation or respiratory arrests. Using univariate analysis factors associated with a greater likelihood of survival include the presence of a witness, bystander-initiated cardiopulmonary resuscitation (CPR), early CPR and VF as the arrest rhythm. Twenty of 155 cases (13%) survived where VF arrest was witnessed by non-EMS personnel.

Rhythm changes during resuscitation from ventricular fibrillation in relation to delay until defibrillation, number of shocks delivered and survival

AIM

To describe rhythm changes during the initial phase of resuscitation from ventricular fibrillation in relation to the interval between collapse and defibrillation, to survival and to bystander-initiated cardiopulmonary resuscitation (CPR).

PATIENTS

All patients who suffered out-of-hospital cardiac arrest between 1980 and 1992, who were reached by the emergency medical service system (EMS), in whom resuscitation attempts were initiated and who were found in ventricular fibrillation.

RESULTS

In all, 1216 patients were included in the study. Among patients who converted to a pulse-generating rhythm after the first defibrillation (n = 119) were 56% discharged from hospital as compared with 6% among patients who converted to asystole. The corresponding figures after the third defibrillation were 49% and 2%, respectively, and after the fifth defibrillation 28% and 7%, respectively. Among patients in whom the first defibrillation took place less than 5 min after collapse, 28% directly converted to a pulse-generating rhythm as compared with 3% when the first defibrillation took place 12 min or more after collapse.

CONCLUSION

Among patients who suffer out-of-hospital cardiac arrest and are found in ventricular fibrillation, there is a strong relationship between survival and initial rhythm changes after defibrillation. These rhythm changes are directly related to the interval between collapse and the first defibrillation.

Continuation of CPR on admission to emergency department after out-of-hospital cardiac arrest. Occurrence, characteristics and outcome

AIM

To describe the occurrence, characteristics and outcome among patients with out-of-hospital cardiac arrest who required continuation of cardiopulmonary resuscitation (CPR) on admission to the emergency department.

PATIENTS

all patients in the municipality of Göteborg who suffered out-of-hospital cardiac arrest, were reached by the emergency medical service (EMS) system and in whom CPR was initiated. Period for inclusion in study: 1 Oct. 1980-31 Dec. 1992.

RESULTS

of 334 out-of-hospital cardiac arrests, 2,319 (68%) were receiving on-going CPR at the time of admission to hospital. Of these, 137 patients (6%) were hospitalized alive and 28 (1.2%) could be discharged from hospital. Of these patients, 39% had a cerebral performance categories (CPC) score of 1 (no cerebral deficiency), 18% had a CPC score of 2 (moderate cerebral deficiency), 36% had a CPC score of 3 (severe cerebral deficiency) and 7% had a CPC score of 4 (coma) at discharge. Among patients discharged. 76% were alive after 1 year.

CONCLUSION

among consecutive patients with out-of-hospital cardiac arrest, CPR was ongoing in 68% of them on admission to hospital. Among these patients, 6% were hospitalized alive and 1.2% were discharged from hospital. Thus, among patients with ongoing CPR on admission to hospital, survivors can be found but they are few in numbers and extensive cerebral damage is frequently present.

Bystander-initiated cardiopulmonary resuscitation out-of-hospital. A first description of the bystanders and their experiences

At present there are about 1 million trained cardiopulmonary resuscitation (CPR) rescuers in Sweden. CPR out-of-hospital is initiated about 2000 times a year in Sweden. However, very little is known about the bystanders' experiences and reactions. The aim of this study was to describe bystander-initiated CPR, the circumstances, the bystander and his experiences. All CPR bystanders in Sweden who reported their resuscitation attempts between 1990 and 1994 were approached with a phone interview and a postal questionnaire, resulting in 742 questionnaires. Bystander-initiated CPR most frequently took place in public places such as the street. The rescuer most frequently had problems with mouth-to-mouth ventilation (20%) and vomiting (18%). More than half (53%) of the rescuers experienced CPR without problems. Ninety-two percent of the bystanders had no hesitation because of fear of contracting the acquired immunodeficiency syndrome (AIDS) virus. Ninety-three percent of the rescuers regarded their intervention as a mainly positive experience. Of 425 interviewed rescuers, 99.5% were prepared to start CPR again.

Prognosis among patients with out-of-hospital cardiac arrest judged as being caused by deterioration of obstructive pulmonary disease

AIM

To describe the prognosis of patients with out-of-hospital cardiac arrest judged to be caused by the deterioration of obstructive pulmonary disease.

PATIENTS

All patients in the community of Göteborg Sweden who suffered out-of-hospital cardiac arrest between 1980 and 1992 attended by our emergency medical service and in whom cardiopulmonary resuscitation was initiated.

METHODS

The etiology of cardiac arrest was determined according to clinical history, observations at resuscitation and findings at autopsy.

RESULTS

There were 3434 cardiac arrests of which 130 (4%) were judged to have been caused by deterioration of obstructive pulmonary disease. Of these patients 50% were found in asystole, 40% in pulseless electrical activity, and only 7% in ventricular fibrillation. Among patients with cardiac arrest caused by obstructive pulmonary disease 21 (16%) were hospitalized alive and six (5%) were discharged from hospital. Among patients who developed cardiac arrest after arrival of the ambulance, 16% were discharged from hospital versus 0% among patients who had arrest prior to arrival of the ambulance.

CONCLUSION

Among patients with out-of-hospital cardiac arrest caused by deterioration of obstructive pulmonary disease, half were found in asystole. Overall, the survival rate was low. This highlights the importance of effective treatment early in the course of deterioration of obstructive pulmonary disease in order to avoid cardiac arrest.

Advanced life support: role of the rural registered nurse

This paper provides a human face to advanced life support (ALS) and its assention within rural nursing practice. Over the past 5 years the issue of defibrillation and who performs it has been debated. This paper will add to the discussion. It examines the history surrounding the development of ALS, education within the hospital and isolated rural setting competency testing. It questions the limited role of current nursing practice and makes recommendations for stretching the boundaries of the nursing role in ALS. Emphasis is placed on the rural perspective and its consequent implications for individuals living in a rural environment.

Life after cardiac arrest; a retrospective study

AIM

We decided to evaluate the life situation of the survivors after out-of-hospital cardiopulmonary resuscitation (CPR).

METHOD

CPR survivors who were 75 years or younger at the time and who were discharged alive from the hospital were identified consecutively. Average follow-up time was 25.5 months, and at follow-up 24% were deceased and 9% were lost. A questionnaire was completed by 93% and 71% were positive to an interview.

RESULTS

Cognitive functions were reduced as well as capacity to perform activities in daily living. This resulted in dependence on other persons for living (nursing homes) and a low return to work. Social isolation was a common complaint. The survivors also reported lower pain awareness than the reference population. As far as other aspects of health-related quality of life, this small group show many similarities with previously evaluated post-infarction patients.

CONCLUSION

Lower pain awareness should be taken into consideration when the CPR patients have ischemic heart disease. If possible, try to prevent social isolation.

Hospital mortality after out-of-hospital cardiac arrest among patients found in ventricular fibrillation

The aim of this study was to describe factors associated with in-hospital mortality among patients being hospitalised after out-of-hospital cardiac arrest and who were found in ventricular fibrillation. The study was set in the community of Göteborg, Sweden. The subjects consisted of all patients who were hospitalised alive after out-of-hospital cardiac arrest, being reached by our mobile coronary care unit and who were found in ventricular fibrillation, between 1981 and 1992. In all, 488 patients fulfilled the inclusion criteria of which 262 (54%) died during initial hospitalization. In a multivariate analysis including age, sex, history of cardiovascular disease, chronic medication prior to arrest and circumstances at the time of arrest, the following appeared as independent predictors of hospital mortality: (1) interval between collapse and first defibrillation (P < 0.001); (2) on chronic medication with diuretics (P < 0.01); (3) age (P < 0.01); (4) bystander initiated CPR (P < 0.05); and (5) a history of diabetes (P < 0.05). In a multivariate analysis considering various aspects of status on admission to hospital, the following were independently associated with death: (1) degree of consciousness (P < 0.001) and (2) systolic blood pressure (P < 0.05). In conclusion, among patients with out of hospital cardiac arrest found in ventricular fibrillation and being hospitalised alive, 54% died in hospital. The in-hospital mortality was related to patient characteristics before the cardiac arrest as well as to factors at the resuscitation itself.