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

Association Between Emergency Medical Services Intervention Volume and Out-of-Hospital Cardiac Arrest Survival: A Propensity Score Matching Analysis

BACKGROUND

Out of hospital cardiac arrest (OHCA) survival rates are very low. An association between institutional OHCA case volume and patient outcomes has been documented. However, whether this applies to prehospital emergency medicine services (EMS) is unknown.

OBJECTIVES

To investigate the association between the volume of interventions by mobile intensive care units (MICU) and outcomes of patients experiencing an OHCA.

METHODS

A retrospective cohort study including adult patients with OHCA managed by medical EMS in five French centers between 2013 and 2020. Two groups were defined depending on the overall annual numbers of MICU interventions: low and high-volume MICU. Primary endpoint was 30-day survival. Secondary endpoints were prehospital return of spontaneous circulation (ROSC), ROSC at hospital admission and favorable neurological outcome. Patients were matched 1:1 using a propensity score. Conditional logistic regression was then used.

RESULTS

2,014 adult patients (69% male, median age 68 [57-79] years) were analyzed, 50.5% (n = 1,017) were managed by low-volume MICU and 49.5% (n = 997) by high-volume MICU. Survival on day 30 was 3.6% in the low-volume group compared to 5.1% in the high-volume group. There was no significant association between MICU volume of intervention and survival on day 30 (OR = 0.92, 95%CI [0.55;1.53]), prehospital ROSC (OR = 1.01[0.78;1.3]), ROSC at hospital admission (OR = 0.92 [0.69;1.21]), or favorable neurologic prognosis on day 30 (OR = 0.92 [0.53;1.62]).

Epidemiology of major heart rhythm and conduction disorders

BACKGROUND

Heart rhythm and conduction disorders cover a variety of pathologies, ranging from the benign to the immediately life threatening.

AIMS

To describe the epidemiology of patients hospitalized for arrhythmias in France, and to estimate the prevalence and mortality associated with these disorders, divided into three separate groups: atrial fibrillation and flutter; conduction disorders; and ventricular tachycardia/cardiac arrest.

METHODS

We looked in the National Health Data System and selected patients who had been hospitalized at least once in 2022 for these diseases and patients who died as a result of these diseases in 2021. The prevalence of these disorders among people alive on 1st January 2023 was estimated by combining previous hospitalizations and people in receipt of 100% coverage for a registered long-term disease.

RESULTS

At 1st January 2023, the prevalence of patients who had been hospitalized with major rhythm and conduction disorders was 2,740,141: 2,027,900 with atrial fibrillation/flutter; 999,692 with conduction disorders; and 214,989 with ventricular tachycardia/cardiac arrest. In 2022, respectively 90,502, 48,268 and 16,930 were hospitalized for these conditions, which equate to rates of 169.5, 68.3, and 31.7 per 100,000 inhabitants, respectively. Several departments in the Hauts-de-France and Grand-Est regions had rates>20% above the national rate. The rate of ventricular tachycardia/cardiac arrest was 40% higher among residents of the most deprived municipalities than among residents of the least deprived municipalities. Mortality at the end of hospitalization reached 44% for patients hospitalized for ventricular tachycardia/cardiac arrest.

CONCLUSIONS

Arrhythmias and conduction disorders affect a significant proportion of the population, leading to a large number of hospitalizations and procedures, particularly ablation techniques and pacemaker/defibrillator implantation. Given the extent of regional disparities and the impact of the socioeconomic status of the municipality of residence, targeted prevention and screening strategies should be implemented.

OECD indicator 'AMI 30-day mortality' is neither comparable between countries nor suitable as indicator for quality of acute care

BACKGROUND

Hospital mortality after acute myocardial infarction (AMI, ICD-10: I21-I22) is used as OECD indicator of the quality of acute care. The reported AMI hospital mortality in Germany is more than twice as high as in the Netherlands or Scandinavia. Yet, in Europe, Germany ranks high in health spending and availability of cardiac procedures. We provide insights into this contradictory situation.

METHODS

Information was collected on possible factors causing the reported differences in AMI mortality such as prevalence of risk factors or comorbidities, guideline conform treatment, patient registration, and health system structures of European countries. International experts were interviewed. Data on OECD indicators 'AMI 30-day mortality using unlinked data' and 'average length of stay after AMI' were used to describe the association between these variables graphically and by linear regression.

RESULTS

Differences in prevalence of risk factors or comorbidities or in guideline conform acute care account only to a smaller extent for the reported differences in AMI hospital mortality. It is influenced mainly by patient registration rules and organization of health care. Non-reporting of day cases as patients and centralization of AMI care-with more frequent inter-hospital patient transfers-artificially lead to lower calculated hospital mortality. Frequency of patient transfers and national reimbursement policies affect the average length of stay in hospital which is strongly associated with AMI hospital mortality (adj R2 = 0.56). AMI mortality reported from registries is distorted by different underlying populations.

CONCLUSION

Most of the variation in AMI hospital mortality is explained by differences in patient registration and organization of care instead of differences in quality of care, which hinders cross-country comparisons of AMI mortality. Europe-wide sentinel regions with comparable registries are necessary to compare (acute) care after myocardial infarction.

[Patients hospitalized in the ICU for acute coronary syndrome from 2012 to 2021: A single-center retrospective study]

INTRODUCTION

Acute Coronary Syndrome (ACS) are one of the main causes of mortality in France. Patients presenting with ACS are typically hospitalized in a specialized cardiology ward. The main objective of this study was to describe, characterize and evaluate the outcome of patients hospitalized for ACS in a generalist intensive care unit (rather than a cardiac care unit).

METHODS

This was a retrospective study. Our population consisted of ACS patients admitted to an intensive care unit in a hospital center (Centre Hospitalier de Troyes) between 2012 and 2021. All patients admitted for ACS to the intensive care unit and who underwent coronary angiography were included.

RESULTS

In 10 years, 104 patients, or 3.8% of ACS patients who underwent coronary angiography were admitted to intensive care. The majority were admitted after recovered cardiac arrest (72%) and were in cardiogenic shock (68%), accounting for a high in-hospital mortality (45.2%). In-hospital mortality was 45.2%. In multivariate analysis, the GRACE score was associated with in-hospital mortality (OR for each additional point = 1.024, 95% confidence interval 1.006-1.045, p = 0.01). Among the survivors, 88% had good neurological function when leaving the hospital.

DISCUSSION

Mortality of ACS patients in intensive care was close to 50%. However, the neurological prognosis of the surviving patients was good. This population is rarely mentioned in the literature, and deserves to be evaluated by multicenter, prospective registries, with a view to improving management and prognosis.

Incidence, characteristics, and prehospital outcomes of out-of-hospital cardiac arrest in Qatar: a nationwide gender-based investigation

BACKGROUND

Research on incidence and characteristics of Out-of-Hospital Cardiac Arrest (OHCA) in the Middle East is limited. We assessed the incidence, prehospital characteristics, and outcomes of OHCA in Qatar, a Middle Eastern country. Subsequently, we performed gender-specific analysis.

METHODS

This was a retrospective examination of data obtained from the OHCA registry at Hamad Medical Corporation (HMC) in Qatar from 2017 to 2022. We included adults, non-traumatic, EMS-treatment OHCA. We calculated the incidence of adult OHCA and conducted descriptive analyses for prehospital characteristics, and prehospital outcomes presented by return of spontaneous circulation (ROSC). We evaluated gender differences in prehospital characteristics and ROSC using Student's t-test and the Chi-Square test as appropriate. Furthermore, we conducted a multivariable logistic regression analysis to investigate the correlation between gender and achieving ROSC.

RESULTS

We included 4,306 adult OHCA patients, with 869 (20.2%) being females. The mean annual incidence of adult OHCA was 27.4 per 100,000 population-year. Males had a higher annual incidence of OHCA than females. Among all cases, 36.3% occurred in a public location, 25.8% had an initial shockable rhythm, and 28.8% achieved ROSC. Males had a higher proportion of bystander CPR, arrests in public locations, and initial shockable rhythms. While unadjusted analysis showed no significant gender differences in achieving ROSC, adjusted analysis revealed that male gender was associated with higher odds of achieving ROSC (adjusted OR male vs. female 1.38, 95% CI 1.15-1.66, p < 0.001).

CONCLUSIONS

Approximately 720 adults undergo non-traumatic OHCA in Qatar every year, with a higher incidence observed in males. Male gender was associated with higher odds of achieving ROSC. Further gender-specific research in OHCA intervention and outcome in the Middle East is required.

Addressing out-of-hospital cardiac arrest with current technology advances: Breaking the deadlock with a mobile network

Out-of-hospital cardiac arrest (OHCA) is a global public health problem, with survival rates remaining low at around 10% or less despite widespread cardiopulmonary resuscitation (CPR) training and availability of automated external defibrillators (AEDs). This is partly due to the challenges of knowing when and where a sudden OHCA occurs and where the nearest AED is located. In response, countries around the world have begun to use network technology-based smartphone applications. These applications are activated by emergency medical service dispatchers and alert preregistered volunteer first responders (VFRs) to nearby OHCAs using Global Positioning System localization. Accumulating evidence, although mostly from observational studies, shows their effectiveness in increasing the rate of bystander CPR, defibrillation, and patient survival. Current guidelines recommend the use of these VFR alerting systems, and the results of ongoing randomized trials are awaited for further dissemination. This article also proposed the concept of a life-saving mobile network (LMN), which uses opportunistic network and wireless sensor network technologies to create a dynamic mesh network of potential victims, rescuers, and defibrillators. The LMN works by detecting a fatal arrhythmia with a wearable sensor device, localizing the victim and the nearest AED with nearby smartphones, and notifying VFRs through peer-to-peer communication. While there are challenges and limitations to implementing the LMN in society, this innovative network technology would reduce the tragedy of sudden cardiac death from OHCA.

Time Is Life: Golden Ten Minutes on Scene-EuReCa_Serbia 2014-2023

Background and Objectives: This study analyzed the frequency of factors influencing the course and outcomes of out-of-hospital cardiac arrest (OHCA) in Serbia and the prediction of pre-hospital outcomes and survival. Materials and Methods: Data were collected during the period from 1 October 2014, to 31 September 2023, according to the protocol of the EuReCa_One study (clinical trial ID number NCT02236819). Results: Overall 9303 OHCA events were registered with a median age of 71 (IQR 61-81) years and 59.7% of them being males. The annual OHCA incidence was 85.60 ± 20.73/100,000. Within all bystander-witnessed cases, bystander-initiated cardiopulmonary resuscitation in 15.3%. Within the resuscitation-initiated group, return-of-spontaneous circulation (ROSC) on scene (any ROSC) was present in 1037/4053 cases (25.6%) and ROSC on admission to the nearest hospital in 792/4053 cases (19.5%), while 201/4053 patients survived to hospital discharge (5.0%). Predictive potential on pre-hospital outcomes was shown by several factors. Also, of all patients having any ROSC, 89.2% were admitted to the hospital alive. The probability of any ROSC dropped below 50% after 17 min passed after the emergency call and 10 min after the EMS scene arrival. These time intervals were significantly associated with survival to hospital discharge (p < 0.001). Five-minute time intervals between both emergency calls and any ROSC and EMS scene arrival and any ROSC also had a significant predictive potential for survival to hospital discharge (p < 0.001, HR 1.573, 95% CI 1.303-1.899 and p = 0.017, HR 1.184, 95% CI 1.030-1.361, respectively). Conclusions: A 10-min time on scene to any ROSC is a crucial time-related factor for achieving any ROSC, and indirectly admission ROSC and survival to hospital discharge, and represents a golden time interval spent on scene in the management of OHCA patients. A similar effect has a time interval of 17 min from an emergency call. Further investigations should be focused on factors influencing these time intervals, especially time spent on scene.

Comparison of chest compression quality between the overlapping hands and interlocking hands techniques: A randomised cross-over trial

BACKGROUND

Performing quality chest compressions is fundamental to the management of cardiopulmonary arrest. The aim of this study was to compare the efficacy of two hand positions: overlapping versus interlocking for performing chest compressions during cardiopulmonary arrest.

METHODS

The HP2C (for Hands Position and Chest Compression) was a prospective, randomised, open-label, cross-over, single-centre study. Participants were recruited from the Emergency Medical Service (EMS) teams and the prehospital firefighter teams. They were randomised to start chest compressions either with overlapping or interlocking hands and then performed the other technique after a washout period. The judgement criteria were the overall chest compressions success score generated by software in accordance with ILCOR recommendations, the quality of compression, release, rate and subjective intensity measured with the Borg scale.

RESULTS

A total of 100 participants were included in the study. The mean age of the caregivers was 38 ± 9.3 years. The median CPR score was 79.5% IQR [48.5-94.0] in the overlapping hands group and 71% IQR [38.0-92.8] in the interlocking hands group (p-value = 0.37). There was no significant difference for the other criteria, especially no difference in term of intensity of effort. However, there was a trend towards better results with overlapping hands.

CONCLUSIONS

This study failed to demonstrate a difference in effectiveness between overlapping and interlocking hand chest compressions during cardiopulmonary resuscitation.

A Motorcycle Paramedic Increases the Survival Rate of Patients after OHCA

Background and Objectives: Despite advancements in modern medicine, the survival rate of patients after out-of-hospital cardiac arrest (OHCA) remains low. The proportion of OHCA patients who could be saved under ideal circumstances is unknown. A significant portion of patients experience cardiac arrest due to irreversible conditions. The survival of patients with reversible causes depends on the prompt initiation of basic life support (BLS) and early defibrillation. In order to increase the chances of survival, the motorcycle paramedic (MP) project was implemented in Ljubljana in 2003. The MP is equipped with an AED. In the case of OHCA with a shockable rhythm, he performs defibrillation before the arrival of the emergency medical team (EMT). The aim of this study was to evaluate whether the MP, by reducing response times to OHCA patients, increases the survival and outcome of these patients compared to the EMT. Materials and Methods: A retrospective analysis of OHCA cases within the area covered by Ljubljana Emergency Medical Service (EMS) was conducted for the period from January 2003 to December 2022. Instances where the MP arrived at the scene before the EMT were considered MP interventions and classified as the MP group; all other interventions were classified as the EMT group. Results: Between January 2003 and December 2022, the EMT performed resuscitation on 3352 patients. In 316 cases, the MP was simultaneously activated and arrived at the scene before the EMT. The response time in the MP group was shorter compared to the EMT group (7.7 ± 4.1 min vs. 9.9 ± 6.5 min, p < 0.001). In 16 patients, return of spontaneous circulation (ROSC) was achieved before the arrival of the EMT. The MP group had a higher ROSC rate, a larger proportion of patients were discharged from the hospital and there were more patients with a good neurological outcome compared to the EMT group (44.3% vs. 36.9%, p = 0.009; 18.7% vs. 13.0%, p = 0.005; 15.9% vs. 10.6%, p = 0.004, respectively). Conclusion: This study has demonstrated that the implementation of the MP into the EMS in Ljubljana has resulted in shorter response times, an increased survival rate and improved neurological outcome for OHCA patients.

Out-of-hospital cardiac arrests occurring at school in France: A nation-wide retrospective cohort study from the RéAC registry

AIM

We sought to describe the characteristics of at-school out-of-hospital cardiac arrests cases, subsequent basic life support, as well as ultimate patient outcomes.

METHODS

This was a nation-wide, multicentre, retrospective cohort study from the French national population-based RéAC out-of-hospital cardiac arrest registry (July 2011 - March 2023). We compared the characteristics and outcomes of cases occurring at schools vs. in other public places.

RESULTS

Of the 149,088 national out-of-hospital cardiac arrests, 25,071 were public: 86 (0.3%) and 24,985 (99.7%) in schools and other public places, respectively. At-school out-of-hospital cardiac arrests, in comparison to other public places, were: significantly younger (median: 42.5 vs. 58 years, p < 0.001); more commonly of a medical cause (90.7% vs. 63.8%, p < 0.001), more commonly bystander-witnessed (93.0% vs. 73.4%, p < 0.001) and recipients of bystander cardiopulmonary resuscitation (78.8% vs. 60.6%, p = 0.001) with shorter median no-flow durations (2 min. vs. 7 min.); with greater bystander automated external defibrillator application (38.9% vs. 18.4%) and defibrillation (23.6%, vs. 7.9%; all p < 0.001). At-school patients had greater rates of return of spontaneous circulation than out-of-school ones (47.7%, vs. 31.8%; p = 0.002), higher rates of survival at arrival at hospital (60.5% vs. 30.7%; p < 0.001) and at 30-days (34.9% vs. 11.6%; p < 0.001), and survival with favourable neurological outcomes at 30 days (25.9% vs. 9.2%; p < 0.001).

CONCLUSION

At-school out-of-hospital cardiac arrests were rare in France, however demonstrated favourable prognostic features and outcomes. The use of automated external defibrillators in at-school cases, while more common than cases occurring elsewhere, should be improved.

Outcomes after Clinical and Traumatic Out-of-Hospital Cardiac Arrest

BACKGROUND

Data on out-of-hospital cardiac arrest are still scarce, very varied, and indicate a poor prognosis for traumatic events.

OBJECTIVES

To describe the out-of-hospital/in-hospital survival, survival time, and neurological conditions of those treated by advanced life support units and submitted to cardiopulmonary resuscitation and compare the results of clinical and traumatic cardiac arrests.

METHODS

This is a cohort study carried out in three stages; in the first two, data were collected from the Mobile Emergency Care Service forms and medical records; then, the Brain Performance Category Scale was applied in the third stage. The sample consisted of resuscitated victims aged ≥18 years. Fisher's and log-rank tests were used to compare the causes, considering a significance level of 5%.

RESULTS

852 patients were analyzed; 20.66% were hospitalized, 4.23% survived until transfer or discharge, and 58.33% had a favorable outcome one year after arrest. There was an association between pre/in-hospital survival and the nature of the occurrence (p=0.026), but there was no difference between the survival curves (p=0.6).

CONCLUSIONS

Survival of hospitalization after out-of-hospital cardiac arrest was low; however, most who survived to be discharged achieved a favorable outcome after one year. The survival time of those hospitalized after clinical and traumatic events were similar, but pre-hospital survival was higher among trauma patients.

Factors associated with circulatory death after out-of-hospital cardiac arrest: a population-based cluster analysis

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is a common cause of death. Early circulatory failure is the most common reason for death within the first 48 h. This study in intensive care unit (ICU) patients with OHCA was designed to identify and characterize clusters based on clinical features and to determine the frequency of death from refractory postresuscitation shock (RPRS) in each cluster.

METHODS

We retrospectively identified adults admitted alive to ICUs after OHCA in 2011-2018 and recorded in a prospective registry for the Paris region (France). We identified patient clusters by performing an unsupervised hierarchical cluster analysis (without mode of death among the variables) based on Utstein clinical and laboratory variables. For each cluster, we estimated the hazard ratio (HRs) for RPRS.

RESULTS

Of the 4445 included patients, 1468 (33%) were discharged alive from the ICU and 2977 (67%) died in the ICU. We identified four clusters: initial shockable rhythm with short low-flow time (cluster 1), initial non-shockable rhythm with usual absence of ST-segment elevation (cluster 2), initial non-shockable rhythm with long no-flow time (cluster 3), and long low-flow time with high epinephrine dose (cluster 4). RPRS was significantly associated with this last cluster (HR, 5.51; 95% confidence interval 4.51-6.74).

CONCLUSIONS

We identified patient clusters based on Utstein criteria, and one cluster was strongly associated with RPRS. This result may help to make decisions about using specific treatments after OHCA.

Comparison of out-of-hospital cardiac arrests during the COVID-19 pandemic with those before the pandemic: an updated systematic review and meta-analysis

The coronavirus disease of 2019 (COVID-19) pandemic, directly and indirectly, affected the emergency medical care system and resulted in worse out-of-hospital cardiac arrest (OHCA) outcomes and epidemiological features compared with those before the pandemic. This review compares the regional and temporal features of OHCA prognosis and epidemiological characteristics. Various databases were searched to compare the OHCA outcomes and epidemiological characteristics during the COVID-19 pandemic with before the pandemic. During the COVID-19 pandemic, survival and favorable neurological outcome rates were significantly lower than before. Survival to hospitalization, return of spontaneous circulation, endotracheal intubation, and use of an automated external defibrillator (AED) decreased significantly, whereas the use of a supraglottic airway device, the incidence of cardiac arrest at home, and response time of emergency medical service (EMS) increased significantly. Bystander CPR, unwitnessed cardiac arrest, EMS transfer time, use of mechanical CPR, and in-hospital target temperature management did not differ significantly. A subgroup analysis of the studies that included only the first wave with those that included the subsequent waves revealed the overall outcomes in which the epidemiological features of OHCA exhibited similar patterns. No significant regional differences between the OHCA survival rates in Asia before and during the pandemic were observed, although other variables varied by region. The COVID-19 pandemic altered the epidemiologic characteristics, survival rates, and neurological prognosis of OHCA patients. Review registration: PROSPERO (CRD42022339435).

Airway management in out-of-hospital cardiac arrest: A systematic review and network meta-analysis

OBJECTIVES

Airway management during cardiopulmonary resuscitation is particularly important for patients with out-of-hospital cardiac arrest (OHCA). This study was performed to compare the efficacy of the most commonly used out-of-hospital airway management methods in increasing the survival to discharge in patients with OHCA.

METHODS

We screened all relevant literature from database inception to 21st January 2019 in PubMed, Web of Science, Embase, and the Cochrane Library. We included all randomized controlled trials (RCTs) of airway management for OHCA in adults (≥16 years of age) with no limitations on publication status, publication date, or language. The primary outcome was survival to discharge. The secondary outcomes were the overall airway technique success rate, return of spontaneous circulation, and survival to hospital admission.

RESULTS

Overall, from 1986 to 2018, 9 RCTs involving 13,949 patients were included in the network meta-analysis, and the efficacy of six airway management methods for patients with OHCA were compared. However, none of the results were statistically significant.

CONCLUSIONS

As the gold standard of airway management for patients with out-of-hospital cardiac arrest in most countries, endotracheal intubation (ETI) has been widely used for many years. However, our systematic review and network meta-analysis showed that ETI is no better than other methods in increasing the survival to discharge. This is not directly proportional to the various preparations required before ETI. Additional randomized controlled trials are needed to identify more effective methods and improve patients' outcome.

Bystander basic life support and survival after out-of-hospital cardiac arrest: A propensity score matching analysis

INTRODUCTION AND OBJECTIVES

In out-of-hospital cardiac arrest, early recognition, calling for emergency medical assistance, and early cardiopulmonary resuscitation are acknowledged to be the three most important components in the chain of survival. However, bystander basic life support (BLS) initiation rates remain low. The objective of the present study was to evaluate the association between bystander BLS and survival after an out-of-hospital cardiac arrest (OHCA).

METHODS

We conducted a retrospective cohort study of all patients with OHCA with a medical etiology treated by a mobile intensive care unit (MICU) in France from July 2011 to September 2021, as recorded in the French National OHCA Registry (RéAC). Cases in which the bystander was an on-duty fire fighter, paramedic, or emergency physician were excluded. We assessed the characteristics of patients who received bystander BLS vs. those who did not. The two classes of patient were then matched 1:1, using a propensity score. Conditional logistic regression was then used to probe the putative association between bystander BLS and survival.

RESULTS

During the study, 52,303 patients were included; BLS was provided by a bystander in 29,412 of these cases (56.2%). The 30-day survival rates were 7.6% in the BLS group and 2.5% in the no-BLS group (p < 0.001). After matching, bystander BLS was associated with a greater 30-day survival rate (odds ratio (OR) [95% confidence interval (CI)] = 1.77 [1.58-1.98]). Bystander BLS was also associated with greater short-term survival (alive on hospital admission; OR [95%CI] = 1.29 [1.23-1.36]).

CONCLUSIONS

The provision of bystander BLS was associated with a 77% greater likelihood of 30-day survival after OHCA. Given than only one in two OHCA bystanders provides BLS, a greater focus on life saving training for laypeople is essential.

Out-of-Hospital Cardiac Arrest Prospective Epidemiology Monitoring during the First Five Years of EuReCa Program Implementation in Serbia

INTRODUCTION

Poor outcome is still a challenging concern in patients with out-of-hospital cardiac arrest (OHCA) world-wide and there are large differences between European countries regarding not only incidence rates, but survival rates as well. In 2014, Serbian Resuscitation Council initiated regular data collection on epidemiology of OHCA, according to the European Registry of Cardiac Arrest (EuReCa) study protocol.

STUDY OBJECTIVE

The aim of this study is to analyze the results of the first five-year period after initiation of EuReCa study protocol elements implementation in OHCA epidemiological data collection in Serbia.

METHODS

The observed period in this study is about the data on OHCA, collected within the observed area of 16 municipalities covering 1,604,015 citizens, during the period from October 1, 2014 - December 31, 2019. The study included data on all-cause OHCA in both adult and pediatric patients, according to the EuReCa One study protocol, of which all segments were observed.

RESULTS

Within the study period, 5,196 OHCA patients were observed with annual incidence of 83.60/100,000. Of all registered events, 43.9% were witnessed. The most common collapse location was patient's residence (88.7%). Within the group of initiated cardiopulmonary resuscitation (CPR), cardiac etiology was observed in 80.5% of cases and shockable rhythm in 21.7%. Return of spontaneous circulation (ROSC) prior to hospital admission was significantly more frequently achieved and maintained on admission in witnessed cases, cases occurring out of patient's residence, and in cases with shockable initial rhythm (P <.01).

CONCLUSION

The OHCA incidence in Serbia is comparable with the incidence in the majority of European countries, and survival rates are now significantly higher in Utstein events compared to previous results from Serbia. Enrolment of witnessing bystanders in initiating CPR measures remains a concern requiring effort towards understanding of CPR initiation importance and education of general population in administering CPR measures.

Drones delivering automated external defibrillators: A new strategy to improve the prognosis of out-of-hospital cardiac arrest

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is a serious threat to human life and health, characterized by high morbidity and mortality. However, given the limitations of the current emergency medical system (EMS), it is difficult to immediately treat patients who experience OHCA. It is well known that rapid defibrillation after cardiac arrest is essential for improving the survival rate of OHCA, yet automated external defibrillators (AED) are difficult to obtain in a timely manner.

OBJECTIVE

This review illustrates the feasibility and advantages of AED delivery by drones by surveying current studies on drones, explains that drones are a new strategy in OHCA, and finally proposes novel strategies to address existing problems with drone systems.

RESULTS

The continuous development of drone technology has been beneficial for patients who experience OHCA, as drones have demonstrated powerful capabilities to provide rapid delivery of AED. Drones have great advantages over traditional EMS, and the delivery of AED by drones for patients with OHCA is a new strategy. However, the application of this new strategy in real life still has many challenges.

CONCLUSION

Drones are promising and innovative tools. Many studies have demonstrated that AED delivery by drones is feasible and cost-effective; however, as a new strategy to improve the survival rate of OHCA patients, there remain problems to be solved. In the future, more in-depth investigations need to be conducted.

Association between location of out-of-hospital cardiac arrest, on-scene socioeconomic status, and accessibility to public automated defibrillators in two large metropolitan areas in Canada and France

AIM

To compare walking access times to automated external defibrillators (AEDs) between area-level quintiles of socioeconomic status (SES) in out-of-hospital cardiac arrest (OHCA) cases occurring in 2 major urban regions of Canada and France.

METHODS

This was an international, multicenter, retrospective cohort study of adult, non-traumatic OHCA cases in the metropolitan Vancouver (Canada) and Rhône County (France) regions that occurred between 2014 and 2018. We calculated area-level SES for each case, using quintiles of country-specific scores (Q5 = most deprived). We identified AED locations from local registries. The primary outcome was the simulated walking time from the OHCA location to the closest AED (continuous and dichotomized by a 3-minute 1-way threshold). We fit multivariate models to analyze the association between OHCA-to-AED walking time and outcomes (Q5 vs others).

RESULTS

A total of 6,187 and 3,239 cases were included from the Metro Vancouver and Rhône County areas, respectively. In Metro Vancouver Q5 areas (vs Q1-Q4), areas, AEDs were farther from (79 % over 400 m from case vs 67 %, p < 0.001) and required longer walking times to (97 % above 3 min vs 91 %, p < 0.001) cases. In Rhône Q5 areas, AEDs were closer than in other areas (43 % over 400 m from case vs 50 %, p = 0.01), yet similarly poorly accessible (85 % above 3 min vs 86 %, p = 0.79). In multivariate models, AED access time ≥ 3 min was associated with decreased odds of survival at hospital discharge in Metro Vancouver (odds ratio 0.41, 95 % CI [0.23-0.74], p = 0.003).

CONCLUSIONS

Accessibility of public AEDs was globally poor in Metro Vancouver and Rhône, and even poorer in Metro Vancouver's socioeconomically deprived areas.

Individual-level income and out-of-hospital cardiac arrest survival in men and women

Objective

Area-level socioeconomic factors are known to associate with chances to survive out-of-hospital cardiac arrest (OHCA survival). However, the relationship between individual-level socioeconomic factors and OHCA survival in men and women is less established. This study investigated the association between individual-level income and OHCA survival in men and women, as well as its contribution to outcome variability and mediation by resuscitation characteristics.

Methods

A cross-sectional cohort study using data from a Dutch community-based OHCA registry was performed. We included 5395 patients aged≥25 years with OHCA from a presumed cardiac cause. Household income, derived from Statistics Netherlands, was stratified into quartiles. The association between survival to hospital discharge and household income was analysed using multivariable logistic regression adjusting for age, sex and resuscitation characteristics.

Results

Overall women had lower household income than men (median €18 567 vs €21 015), and less favourable resuscitation characteristics. Increasing household income was associated with increased OHCA survival in both men and women in a linear manner (Q4 vs Q1: OR 1.63 95% CI (1.24 to 2.16) in men, and 2.54 (1.43 to 4.48) in women). Only initial rhythm significantly changed the ORs for OHCA survival with>10% in both men and women. Household income explained 3.8% in men and 4.3% in women of the observed variance in OHCA survival.

Conclusion

Both in men and women, higher individual-level household income was associated with a 1.2-fold to 2.5-fold increased OHCA survival to hospital discharge, but explained only little of outcome variability. A shockable initial rhythm was the most important resuscitation parameter mediating this association. Our results do not support the need for immediate targeted interventions on actionable prehospital resuscitation care characteristics.

One-Year Follow-Up of Patients Admitted for Emergency Coronary Angiography after Resuscitated Cardiac Arrest

(1) Background: Despite the improvement of the in-hospital survival rate after aborted sudden cardiac death (SCD), cerebral anoxia may have severe neurologic consequences and may impair long-term outcome and quality of life of surviving patients. The aim of this study was to assess neurological outcomes at one year after resuscitated cardiac arrest; (2) Methods: This prospective, observational, and multicentre study included patients >18 yo admitted in the catheterisation laboratory for coronary angiography after aborted SCD between 1 May 2018 and 31 May 2020. Only patients who were discharged alive from hospital were evaluated. The primary endpoint was survival without neurological sequelae at one-year follow-up defined by a cerebral performance category (CPC) of one or two. Secondary end points included all-cause mortality, New York Heart Association (NYHA) functional class, neurologic evaluation at discharge, three-month and one-year follow-up using the CPC scale, and quality of life at 1 year using the Quality of Life after Brain Injury (QOLIBRI) questionnaire; (3) Results: Among 143 patients admitted for SCD within the study period, 61 (42.7%) were discharged alive from hospital, among whom 55 (90.1%) completed the one-year follow-up. No flow and low flow times were 1.9 ± 2.4 min and 16.5 ± 10.4 min, respectively. For 93.4% of the surviving patients, an initial shockable rhythm (n = 57) was observed and acute coronary syndrome was diagnosed in 75.4% of them (n = 46). At 1 year, survival rate without neurologic sequelae was 87.2% (n = 48). Patients with poor outcome were older (69.3 vs. 57.4 yo; p = 0.04) and had lower body mass index (22.4 vs. 26.7; p = 0.013) and a lower initial Left Ventricle Ejection Fraction (LVEF) (32.1% vs. 40.3%; p = 0.046). During follow-up, neurological status improved in 36.8% of patients presenting sequelae at discharge, and overall quality of life was satisfying for 66.7% of patients according to the QOLIBRI questionnaire; (4) Conclusions: Among patients admitted to the catheterisation laboratory for aborted SCD, mainly related to Acute Coronary Syndrom (ACS), less than a half of them were alive at discharge. However, the one-year survival rate without neurological sequelae was high and overall quality of life was good.

Organ donation after out-of-hospital cardiac arrest: a population-based study of data from the Paris Sudden Death Expertise Center

BACKGROUND

Organ shortage is a major public health issue, and patients who die after out-of-hospital cardiac arrest (OHCA) could be a valuable source of organs. Here, our objective was to identify factors associated with organ donation after brain death complicating OHCA, in unselected patients entered into a comprehensive real-life registry covering a well-defined geographic area.

METHODS

We prospectively analyzed consecutive adults with OHCA who were successfully resuscitated, but died in intensive care units in the Paris region in 2011-2018. The primary outcome was organ donation after brain death. Independent risk factors were identified using logistic regression analysis. One-year graft survival was assessed using Cox and log-rank tests.

RESULTS

Of the 3061 included patients, 136 (4.4%) became organ donors after brain death, i.e., 28% of the patients with brain death. An interaction between admission pH and post-resuscitation shock was identified. By multivariate analysis, in patients with post-resuscitation shock, factors associated with organ donation were neurological cause of OHCA (odds ratio [OR], 14.5 [7.6-27.4], P < 0.001), higher pH (OR/0.1 increase, 1.3 [1.1-1.6], P < 0.001); older age was negatively associated with donation (OR/10-year increase, 0.7 [0.6-0.8], P < 0.001). In patients without post-resuscitation shock, the factor associated with donation was neurological cause of OHCA (OR, 6.9 [3.0-15.9], P < 0.001); higher pH (OR/0.1 increase, 0.8 [0.7-1.0], P = 0.04) and OHCA at home (OR, 0.4 [0.2-0.7], P = 0.006) were negatively associated with organ donation. One-year graft survival did not differ according to Utstein characteristics of the donor.

CONCLUSIONS

4% of patients who died in ICU after OHCA led to organ donation. Patients with OHCA constitute a valuable source of donated organs, and special attention should be paid to young patients with OHCA of neurological cause.

Supraglottic airway device to improve ventilation success and reduce pulmonary aspiration during cardio-pulmonary resuscitation by basic life support rescuers: a randomised cross-over human cadaver study

Objectives: Early airway management during cardiopulmonary resuscitation (CPR) prevents aspiration of gastric contents. Endotracheal intubation is the gold standard to protect airways, but supraglottic airway devices (SGA) may provide some protection with less training. Bag-mask ventilation (BMV) is the most common method used by rescuers. We hypothesized that SGA use by first rescuers during CPR could increase ventilation success rate and also decrease intragastric pressure and pulmonary aspiration.Methods: We performed a randomized cross-over experimental trial on human cadavers. Protocol A: we assessed the rate of successful ventilation (chest rise), intragastric pressure, and CPR key time metrics. Protocol B: cadaver stomachs were randomized to be filled with 300 mL of either blue or green serum saline solution through a Foley catheter. Each rescuer was randomly assigned to use SGA or BMV during a 5-minute standard CPR period. Then, in a crossover design, the stomach was filled with the second colour solution and another 5-minute CPR period was performed using the other airway method. Pulmonary aspiration, defined as the presence of coloured solution below the vocal cords, was assessed by a blinded operator using bronchoscopy. A generalized linear mixed model was used for statistical analysis.Results: Protocol A: Forty-eight rescuers performed CPR on 11 cadavers. Median ventilation success was higher with SGA than BMV: 75.0% (IQR: 59.8-87.3) vs. 34.7% (IQR: 25.0-50.0), (p = 0.003). Gastric pressure and differential (maximum minus minimum) gastric pressure were lower in the SGA group: 2.21 mmHg (IQR: 1.66; 2.68) vs. 3.02 mmHg (IQR: 2.02; 4.22) (p = 0.02) and 5.70 mmHg (IQR: 4.10; 7.60) vs. 8.05 mmHg (IQR: 5.40; 11.60) (p = 0.05). CPR key times were not different between groups. Protocol B: Ten cadavers were included with 20 CPR periods. Aspiration occurred in 2 (20%) SGA procedures and 5 (50%) BMV procedures (p = 0.44).Conclusion: Use of SGA by rescuers improved the ventilation success rate, decreased intragastric pressure, and did not affect key CPR metrics. SGA use by basic life support rescuers appears feasible and efficient.

Sex differences in incidence of out-of-hospital cardiac arrest across ethnic and socioeconomic groups: A population-based cohort study in the Netherlands

BACKGROUND

Insight into the occurrence of out-of-hospital cardiac arrest (OHCA) within general populations may help to target prevention strategies. Case registries suggest that there may be substantial differences in emergency medical service (EMS)-attended OHCA incidence between men and women, but relative sex differences across ethnic groups and socioeconomic (SES) groups have not been studied. We investigated sex differences in OHCA incidence, overall and across these subgroups.

METHODS

We performed a retrospective population-based cohort study, combining individual-level data on ethnicity and income (as SES measure) from Statistics Netherlands of all men and women aged ≥25 years living in one study region in the Netherlands on 01-01-2009 (n = 1,688,285) with prospectively collected EMS-attended OHCA cases (n = 5676) from the ARREST registry until 31-12-2015. We calculated age-standardised incidence rates of OHCA. Sex differences were assessed with Cox proportional hazards regression analyses, adjusted for age, ethnicity and income, in the overall population, and across ethnic and SES groups.

RESULTS

The age-standardised incidence rate of OHCA was lower in women than in men (30.9 versus 87.3 per 100,000 person-years), corresponding with a hazard ratio (HR) of 0.33 (95% confidence interval [CI] 0.31-0.35). These sex differences in hazard for OHCA existed in all income quintiles (HR range: 0.30-0.35) and ethnic groups (HR range: 0.19-0.40), except among Moroccans (HR 0.89, 95% CI 0.51-1.57).

CONCLUSION

Women have a substantial, yet lower OHCA incidence rate than men. The magnitude of these sex differences did not vary across social strata.

The Effect of Therapeutic Hypothermia after Cardiac Arrest on the Neurological Outcome and Survival-A Systematic Review of RCTs Published between 2016 and 2020

Therapeutic hypothermia is a treatment used for patients who have suffered cardiorespiratory arrest and remain conscious after the recovery of spontaneous circulation. However, its effectiveness is controversial. The objective of this systematic review is to summarize the scientific evidence available about the effect of therapeutic hypothermia on neurological status and survival in this type of patients.

METHODOLOGY

A primary search in CINAHL, CUIDEN, Pubmed, Web of Science, and Scopus databases was carried out. Randomized clinical trials (RCT) published from 2016 to 2020 were selected.

RESULTS

17 studies were selected for inclusion and most relevant data were extracted. Methodological quality was assessed by the RoB tool.

CONCLUSIONS

Although therapeutic hypothermia is a safe technique with few adverse and manageable effects, it has not shown to improve survival rate and neurological status of adult nor pediatric patients. It is possible that its positive effect on neuroprotection could be achieved only by preventing hyperthermia although further investigation is needed.

Endotracheal intubation versus supraglottic procedure in paediatric out-of-hospital cardiac arrest: a registry-based study

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) in children is associated with a low survival rate. Conclusions in the literature are conflicting regarding the best way to handle ventilation. The purpose of this study was to assess the impact of two airway management strategies, endotracheal intubation (ETI) vs. supraglottic procedure, during cardiopulmonary resuscitation (CPR) on 30-day survival in paediatric OHCA.

METHODS

This was a retrospective, observational, multicentre, registry-based study conducted from July 2011 to March 2018. All paediatric OHCA patients under 18 years of age and managed by a mobile intensive care unit were included. The primary endpoint was 30-day survival in a weighted population (based on propensity scores).

RESULTS

Of 1579 children, 1355 (85.8%) received ETI and 224 (14.2%) received supraglottic ventilation during CPR. We observe a lower 30-day survival in the ETI group compared to the supraglottic group (7.7% vs. 14.3%, absolute difference, 6.6 percentage points; 95% confidence interval [CI], 2.3-12.0; propensity-adjusted odds ratio [paOR], 0.39; 95% CI, 0.25-0.62; p < 0.001), and also a poorer neurological outcome (paOR, 0.32; 95% CI, 0.19-0.54; p < 0.001). However, we did not identify any significant association between airway management strategy and return of spontaneous circulation (paOR, 1.15; 95% CI, 0.80-1.65; p = 0.46).

CONCLUSIONS

The findings of this large cohort study suggest that ETI in paediatric OHCA, although performed by trained physicians, is associated with a worse outcome, regardless of traumatic or non-traumatic aetiology.

Out-of-hospital cardiac arrests in the city of Cape Town, South Africa: a retrospective, descriptive analysis of prehospital patient records

OBJECTIVES

While prospective epidemiological data for out-of-hospital cardiac arrest (OHCA) exists in many high-income settings, there is a dearth of such data for the African continent. The aim of this study was to describe OHCA in the Cape Town metropole, South Africa.

DESIGN

Observational study with a retrospective descriptive design.

SETTING

Cape Town metropole, Western Cape province, South Africa.

PARTICIPANTS

All patients with OHCA for the period 1 January 2018-31 December 2018 were extracted from public and private emergency medical services (EMS) and described.

OUTCOME MEASURES

Description of patients with OHCA in terms of demographics, treatment and short-term outcome.

RESULTS

A total of 929 patients with OHCA received an EMS response in the Cape Town metropole, corresponding to an annual prevalence of 23.2 per 100 000 persons. Most patients were adult (n=885; 96.5%) and male (n=526; 56.6%) with a median (IQR) age of 63 (26) years. The majority of cardiac arrests occurred in private residences (n=740; 79.7%) and presented with asystole (n=322; 34.6%). EMS resuscitation was only attempted in 7.4% (n=69) of cases and return of spontaneous circulation (ROSC) occurred in 1.3% (n=13) of cases. Almost all patients (n=909; 97.8%) were declared dead on the scene.

CONCLUSION

To our knowledge, this was the largest study investigating OHCA ever undertaken in Africa. We found that while the incidence of OHCA in Cape Town was similar to the literature, resuscitation is attempted in very few patients and ROSC-rates are negligible. This may be as a consequence of protracted response times, poor patient prognosis or an underdeveloped and under-resourced Chain of Survival in low- to middle-income countries, like South Africa. The development of contextual guidelines given resources and disease burden is essential.

Automated Assessment of Brain CT After Cardiac Arrest-An Observational Derivation/Validation Cohort Study

Objectives

Prognostication of outcome is an essential step in defining therapeutic goals after cardiac arrest. Gray-white-matter ratio obtained from brain CT can predict poor outcome. However, manual placement of regions of interest is a potential source of error and interrater variability. Our objective was to assess the performance of poor outcome prediction by automated quantification of changes in brain CTs after cardiac arrest.

Design

Observational, derivation/validation cohort study design. Outcome was determined using the Cerebral Performance Category upon hospital discharge. Poor outcome was defined as death or unresponsive wakefulness syndrome/coma. CTs were automatically decomposed using coregistration with a brain atlas.

Setting

ICUs at a large, academic hospital with circulatory arrest center.

Patients

We identified 433 cardiac arrest patients from a large previously established database with brain CTs within 10 days after cardiac arrest.

Interventions

None.

Measurements and Main Results

Five hundred sixteen brain CTs were evaluated (derivation cohort n = 309, validation cohort n = 207). Patients with poor outcome had significantly lower radiodensities in gray matter regions. Automated GWR_si (putamen/posterior limb of internal capsule) was performed with an area under the curve of 0.86 (95%-CI: 0.80-0.93) for CTs taken later than 24 hours after cardiac arrest (similar performance in the validation cohort). Poor outcome (Cerebral Performance Category 4-5) was predicted with a specificity of 100% (95% CI, 87-100%, derivation; 88-100%, validation) at a threshold of less than 1.10 and a sensitivity of 49% (95% CI, 36-58%, derivation) and 38% (95% CI, 27-50%, validation) for CTs later than 24 hours after cardiac arrest. Sensitivity and area under the curve were lower for CTs performed within 24 hours after cardiac arrest.

Conclusions

Automated gray-white-matter ratio from brain CT is a promising tool for prediction of poor neurologic outcome after cardiac arrest with high specificity and low-to-moderate sensitivity. Prediction by gray-white-matter ratio at the basal ganglia level performed best. Sensitivity increased considerably for CTs performed later than 24 hours after cardiac arrest.

Rationale, development and implementation of the ReACanROC registry for out-of-hospital cardiac arrests in France and Canada

France and Canada prehospital systems and care delivery in out-of-hospital cardiac arrests (OHCAs) show substantial differences. This article aims to describe the rationale, design, implementation and expected research implications of the international, population-based, France-Canada registry for OHCAs, namely ReACanROC, which is built from the merging of two nation-wide, population-based, Utstein-style prospectively implemented registries for OHCAs attended to by emergency medical services. Under the supervision of an international steering committee and research network, the ReACanROC dataset will be used to run in-depth analyses on the differences in organisational, practical and geographic predictors of survival after OHCA between France and Canada. ReACanROC is the first Europe-North America registry ever created to meet this goal. To date, it covers close to 80 million people over the two countries, and includes approximately 200 000 cases over a 10-year period.

European Resuscitation Council Guidelines 2021: Epidemiology of cardiac arrest in Europe

In this section of the European Resuscitation Council Guidelines 2021, key information on the epidemiology and outcome of in and out of hospital cardiac arrest are presented. Key contributions from the European Registry of Cardiac Arrest (EuReCa) collaboration are highlighted. Recommendations are presented to enable health systems to develop registries as a platform for quality improvement and to inform health system planning and responses to cardiac arrest.

Temporal Trends of Out-of-Hospital Cardiac Arrests Without Resuscitation Attempt by Emergency Medical Services

BACKGROUND

Significant improvements in survival from out-of-hospital cardiac arrest (OHCA) have been reported; however, these are based only on data from OHCA in whom resuscitation is initiated by emergency medical services (EMS). We aimed to assess the characteristics and temporal trends of OHCA without resuscitation attempt by EMS.

METHODS

Prospective population-based study between 2011 and 2016 in the Greater Paris area (6.7 million inhabitants). All cases of OHCA were included in collaboration with EMS units, 48 different hospitals, and forensic units.

RESULTS

Among 15 207 OHCA (mean age 70.7±16.9 years, 61.6% male), 5486 (36.1%) had no resuscitation attempt by EMS. Factors that were independently associated with increase in likelihood of no resuscitation attempt included: age of patients (odds ratio, 1.06 per year [95% CI, 1.05-1.06], P<0.001), female sex (odds ratio, 1.21 [95% CI, 1.10-1.32], P=0.002), OHCA at home location (odds ratio, 3.38 [95%CI, 2.86-4.01], P<0.001), and absence of bystander (odds ratio, 1.94 [95% CI, 1.74-2.16], P<0.001). Overall, the annual number of OHCA increased by 9.1% (from 2923 to 3189, P=0.028). This increase was related to an increase of the annual number of OHCA without resuscitation attempt by EMS by 26.3% (from 993 to 1253, P=0.012), while the annual number of OHCA with resuscitation attempt by EMS did not significantly change (from 1930 to 1936, P=0.416). Considering only cases with resuscitation attempt, survival rate at hospital discharge increased (from 7.3% to 9.5%, P=0.02). However, when considering all OHCA, survival improvement did not reach statistical significance (from 4.8% to 5.7%, P=0.17).

CONCLUSIONS

We demonstrated an increase of the total number of OHCA related to an increase of the number of OHCA without resuscitation attempt by EMS. This increasing proportion of OHCA without resuscitation attempt attenuates improvement in survival rates achieved in EMS-treated patients.

Response Time Threshold for Predicting Outcomes of Patients with Out-of-Hospital Cardiac Arrest

Ambulance response time is a prognostic factor for out-of-hospital cardiac arrest (OHCA), but the impact of ambulance response time under different situations remains unclear. We evaluated the threshold of ambulance response time for predicting survival to hospital discharge for patients with OHCA. A retrospective observational analysis was conducted using the emergency medical service (EMS) database (January 2015 to December 2019). Prehospital factors, underlying diseases, and OHCA outcomes were assessed. Receiver operating characteristic (ROC) curve analysis with Youden Index was performed to calculate optimal cut-off values for ambulance response time that predicted survival to hospital discharge. In all, 6742 cases of adult OHCA were analyzed. After adjustment for confounding factors, age (odds ratio [OR] = 0.983, 95% confidence interval [CI]: 0.975-0.992, p < 0.001), witness (OR = 3.022, 95% CI: 2.014-4.534, p < 0.001), public location (OR = 2.797, 95% CI: 2.062-3.793, p < 0.001), bystander cardiopulmonary resuscitation (CPR, OR = 1.363, 95% CI: 1.009-1.841, p=0.044), EMT-paramedic response (EMT-P, OR = 1.713, 95% CI: 1.282-2.290, p < 0.001), and prehospital defibrillation using an automated external defibrillator ([AED] OR = 3.984, 95% CI: 2.920-5.435, p < 0.001) were statistically and significantly associated with survival to hospital discharge. The cut-off value was 6.2 min. If the location of OHCA was a public place or bystander CPR was provided, the threshold was prolonged to 7.2 min and 6.3 min, respectively. In the absence of a witness, EMT-P, or AED, the threshold was reduced to 4.2, 5, and 5 min, respectively. The adjusted OR of EMS response time for survival to hospital discharge was 1.217 (per minute shorter, CI: 1.140-1299, p < 0.001) and 1.992 (<6.2 min, 95% CI: 1.496-2.653, p < 0.001). The optimal response time threshold for survival to hospital discharge was 6.2 min. In the case of OHCA in public areas or with bystander CPR, the threshold was prolonged, and without witness, the optimal response time threshold was shortened.

Identification of a morning out-of-hospital cardiac arrest cluster of high-incidence: towards a chrono-preventive care strategy

RATIONALE, AIMS, AND OBJECTIVES

The human body is regulated by intrinsic factors which follow a 24-hour biological clock. Implications of a circadian rhythm in the out-of-hospital cardiac arrest (OHCA) are studied but the literature is not consistent. The main objective of our study was to identify temporal cluster of high or low incidence of OHCA occurrence during a day.

METHODS

Multicentre comparative study based on the French national OHCA registry data between 2013 and 2017. After describing the population, the detection of significant temporal clusters of OHCA incidence was achieved using temporal scan statistics based on a Poisson model adjusted for age and gender. Then, comparisons between identified patients clusters and the rest of the population were performed.

RESULTS

During the study, 37 163 medical OHCA victims were included. The temporal scan revealed a significant 3-hour high incidence temporal cluster between 8:00 am and 10:59 am (Relative R = 1.76, P < .001). In the identified cluster, OHCA occurred more out of the home with fewer witnesses, and advanced life support was less attempted in the cluster. No difference was observed on the return of spontaneous circulation, survival at hospital admission, and survival 30 days after the OHCA or at hospital discharge.

CONCLUSIONS

We observed a three-hour morning high incidence peak of OHCA. This high incidence could be explained by different physiological changes in the morning. These changes are well known and the evidence of a morning peak of cardiovascular disease should enable medical teams to adapt care strategy and hospital organization.

Effect of gender on out-of-hospital cardiac arrest survival: a registry-based study

OBJECTIVE

The aim of the study was to compare outcomes after out-of-hospital cardiac arrest (OHCA) between comparable female and male OHCA cohorts in a large nationwide registry.

METHODS

This was a national multicentre retrospective, case-control propensity score-matched study based on French National Cardiac Arrest Registry data from 1 July 2011 to 21 September 2017. Female and male survival rates at D30 were compared.

RESULTS

At baseline 66 395 OHCA victims were included, of which 34.3% were women. At hospital admission, survival was 18.2% for female patients and 20.2% for male patients [odds ratio (OR), 1.138 (1.092-1.185)]; at 30 days, survival was 4.3 and 5.9%, respectively [OR, 1.290 (1.191-1.500)]. After matching (14 051 patients within each group), female patients received less advanced life support by mobile medical team (MMT), they also had a longer no-flow duration and shorter resuscitation effort by MMT than male patients. However, 15.3% of female patients vs. 9.1% of male patients were alive at hospital admission [OR, 0.557 (0.517-0.599)] and 3.2 vs. 2.6% at D30 [OR, 0.801 (0.697-0.921)], with no statistically significant difference in neurological outcome [OR, 0.966 (0.664-1.407)].

CONCLUSIONS

In this large nationwide matched OHCA study, female patients had a better chance of survival with no significant difference in neurological outcome. We also noticed that female patients received delayed care with a shorter resuscitation effort compared to men; these complex issues warrant further specific investigation. Encouraging bystanders to act as quickly as possible and medical teams to care for female patients in the same way as male patients should increase survival rates.

Pre-hospital Prognostic Factors of Out-of-Hospital Cardiac Arrest: The Difference Between Pediatric and Adult

The prognosis of out-of-hospital cardiac arrest (OHCA) is very poor. Although several pre-hospital factors are associated with survival, the different association of pre-hospital factors with OHCA outcomes in pediatric and adult groups remain unclear. To assess the association of pre-hospital factors with OHCA outcomes among pediatric and adult groups, a retrospective observational study was conducted using the emergency medical service (EMS) database in Kaohsiung from January 2015 to December 2019. Pre-hospital factors, underlying diseases, and OHCA outcomes were collected for the pediatric (Age ≤ 20) and adult groups. Kaplan-Meier type plots and multivariable logistic regression were used to analyze the association between pre-hospital factors and outcomes. In total, 7,461 OHCAs were analyzed. After adjusting for EMS response time, bystander CPR, attended by EMT-P, witness, and pre-hospital defibrillation, we found that age [odds ratio (OR) = 0.877, 95% confidence interval (CI): 0.764-0.990, p = 0.033], public location (OR = 7.681, 95% CI: 1.975-33.428, p = 0.003), and advanced airway management (AAM) (OR = 8.952; 95% CI, 1.414-66.081; p = 0.02) were significantly associated with survival till hospital discharge in pediatric OHCAs. The results of Kaplan-Meier type plots with log-rank test showed a significant difference between the pediatric and adult groups in survival for 2 h (p < 0.001), 24 h (p < 0.001), hospital discharge (p < 0.001), and favorable neurologic outcome (p < 0.001). AAM was associated with improved survival for 2 h (p = 0.015), 24 h (p = 0.023), and neurologic outcome (p = 0.018) only in the pediatric group. There were variations in prognostic factors between pediatric and adult patients with OHCA. The prognosis of the pediatric group was better than that of the adult group. Furthermore, AAM was independently associated with outcomes in pediatric patients, but not in adult patients. Age and public location of OHCA were independently associated with survival till hospital discharge in both pediatric and adult patients.

Use of out-of-hospital cardiac arrest registries to assess COVID-19 home mortality

Background

In most countries, the official statistics for the coronavirus disease 2019 (COVID-19) take account of in-hospital deaths but not those that occur at home. The study’s objective was to introduce a methodology to assess COVID-19 home deaths by analysing the French national out-of-hospital cardiac arrest (OHCA) registry (RéAC).

Methods

We performed a retrospective multicentre cohort study based on data recorded in the RéAC by 20 mobile medical teams (MMTs) between March 1st and April 15th, 2020. The participating MMTs covered 10.1% of the French population. OHCA patients were classified as probable or confirmed COVID-19 cases or as non-COVID-19 cases. To achieve our primary objective, we computed the incidence and survival at hospital admission of cases of COVID-19 OHCA occurring at home. Cardiac arrests that occurred in retirement homes or public places were excluded. Hence, we estimated the number of at-home COVID-19-related deaths that were not accounted for in the French national statistics.

Results

We included 670 patients with OHCA. The extrapolated annual incidence of OHCA per 100,000 inhabitants was 91.9 overall and 17.6 for COVID-19 OHCA occurring at home. In the latter group, the survival rate after being taken to the hospital after an OHCA was 10.9%. We estimated that 1322 deaths were not accounted in the French national statistics on April 15, 2020.

Conclusions

The ratio of COVID-19 out-of-hospital deaths to in-hospital deaths was 12.4%, and so the national statistics underestimated the death rate.

Association between prehospital prognostic factors and out-of-hospital cardiac arrest: Effect of rural-urban disparities

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is associated with a poor prognosis and a highly variable survival rate. Few studies have focused on outcomes in rural and urban groups while also evaluating underlying diseases and prehospital factors for OHCAs.

OBJECTIVE

To investigate the relationship between the patient's underlying disease and outcomes of OHCAs in urban areas versus those in rural areas.

METHODS

We reviewed the emergency medical service (EMS) database for information on OHCA patients treated between January 2015 and December 2019, and collected data on pre-hospital factors, underlying diseases, and outcomes of OHCAs. Univariate and multivariate logistic regression analyses were used to evaluate the prognostic factors for OHCA.

RESULTS

Data from 4225 OHCAs were analysed. EMS response time was shorter and the rate of attendance by EMS paramedics was higher in urban areas (p < 0.001 for both). Urban area was a prognostic factor for >24-h survival (odds ratio [OR] = 1.437, 95% confidence interval [CI]: 1.179-1.761). Age (OR = 0.986, 95% CI: 0.979-0.993). EMS response time (OR = 0.854, 95% CI: 0.811-0.898), cardiac arrest location (OR = 2.187, 95% CI: 1.707-2.795), attendance by paramedics (OR = 1.867, 95% CI: 1.483-2.347), and prehospital defibrillation (OR = 2.771, 95% CI: 2.154-3.556) were independent risk factors for survival to hospital discharge, although the influence of an urban area was not significant (OR = 1.211, 95% CI: 0.918-1.584).

CONCLUSIONS

Compared with rural areas, OHCA in urban areas are associated with a higher 24-h survival rate. Shorter EMS response time and a higher probability of being attended by paramedics were noted in urban areas. Although shorter EMS response time, younger age, public location, defibrillation by an automated external defibrillator, and attendance by Emergency Medical Technician-paramedics were associated with a higher rate of survival to hospital discharge, urban area was not an independent prognostic factor for survival to hospital discharge in OHCA patients.

Mobile Smartphone Technology Is Associated With Out-of-hospital Cardiac Arrest Survival Improvement: The First Year "Greater Paris Fire Brigade" Experience

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) remains associated with very high mortality. Accelerating the initiation of efficient cardiopulmonary resuscitation (CPR) is widely perceived as key to improving outcomes. The main goal was to determine whether identification and activation of nearby first responders through a smartphone application named Staying Alive (SA) can improve survival following OHCA in a large urban area (Paris).

METHODS

We conducted a nonrandomized cohort study of all adults with OHCA managed by the Greater Paris Fire Brigade during 2018, irrespective of mobile application usage. We compared survival data in cases where SA did or did not lead to the activation of nearby first responders. During dispatch, calls for OHCA were managed with or without SA. The intervention group included all cases where nearby first responders were successfully identified by SA and actively contributed to CPR. The control group included all other cases. We compared survival at hospital discharge between the intervention and control groups. We analyzed patient data, CPR metrics, and first responders' characteristics.

RESULTS

Approximately 4,107 OHCA cases were recorded in 2018. Among those, 320 patients were in the control group, whereas 46 patients, in the intervention group, received first responder-initiated CPR. After adjustment for confounders, survival at hospital discharge was significantly improved for patients in the intervention group (35% vs. 16%, adjusted odds ratio = 5.9, 95% confidence interval = 2.1 to 16.5, p < 0.001). All CPR metrics were improved in the intervention group.

CONCLUSIONS

We report that mobile smartphone technology was associated with OHCA survival through accelerated initiation of efficient CPR by first responders in a large urban area.

Pulse rate as an alternative, real-time feedback indicator for chest compression rate: a porcine model of cardiac arrest

Feedback indicators can improve chest compression quality during cardiopulmonary resuscitation (CPR). However, the application of feedback indicators in the clinic practice is rare. Pulse oximetry has been widely used and reported to correlate spontaneous circulation restoration during CPR. However, it is unclear if pulse oximetry can monitor the quality of chest compression. We hypothesized that pulse rate monitored by pulse oximetry can be used as a feedback indicator of the chest compression rate during CPR in a porcine model of cardiac arrest. Seven domestic male pigs (30–35 kg) were utilized in this study. Eighteen intermittent chest compression periods of 2 min were performed on each animal. Chest compression and pulse oximetry plethysmographic waveforms were recorded simultaneously. Chest compression and pulse rates were calculated based on both waveforms. Compression interruption and synchronous pulse interruption times were also measured. Agreement was analyzed between pulse rates and synchronous chest compression rates, as well as between compression interruption times and synchronous pulse interruption times. A total of 126 compression periods of 2 min were performed on seven animals. Interclass correlation coefficients and Bland–Altman analysis revealed reliable agreement between pulse rates and synchronous chest compression rates. Similarly, compression interruption and synchronous pulse interruption times obtained also showed high agreement. Pulse rate can be used as an alternative indicator of chest compression rate during CPR in a porcine model of cardiac arrest. Pulse interruption time also can be used to reflect compression interruption time precisely in this model.

Effects of Prehospital Factors on Survival of Out-Of-Hospital Cardiac Arrest Patients: Age-Dependent Patterns

Many prehospital factors that are known to influence survival rates after out-of-hospital cardiac arrest (OHCA) have been rarely studied as to how their influence varies depending on the age. In this study, we tried to find out what prehospital factors affect the survival rate after OHCA by age groups and how large the effect size of those factors is in each age group. We used the South Korean OHCA registry, which includes information on various prehospital factors relating OHCA and final survival status. The association between prehospital factors and survival was explored through logistic regression analyses for each age group. The effects of prehospital factors vary depending on the patient’s age. Being witnessed was relatively more influential in younger patients and the presence of first responders became more important as patients became older. While bystander cardiopulmonary resuscitation (CPR) did not appear to significantly affect survival in younger people, use of an automated external defibrillator (AED) showed the largest effect size on the survival in all age groups. Since the pathophysiology and etiologies of OHCA vary according to age, more detailed information on life support by age is needed for the development and application of more specialized protocols for each age.

A Time-Dependent Propensity Score Matching Approach to Assess Epinephrine Use on Patients Survival Within Out-of-Hospital Cardiac Arrest Care

BACKGROUND

Epinephrine effectiveness and safety are still questioned. It is well known that the effect of epinephrine varies depending on patients' rhythm and time to injection.

OBJECTIVE

We aimed to assess the association between epinephrine use during out-of-hospital cardiac arrest (OHCA) care and patient 30-day (D30) survival.

METHODS

Between 2011 and 2017, 27,008 OHCA patients were included from the French OHCA registry. We adjusted populations using a time-dependent propensity score matching. Analyses were stratified according to patient's first rhythm. After matching, 2837 pairs of patients with a shockable rhythm were created and 20,950 with a nonshockable rhythm.

RESULTS

Whatever the patient's rhythm (shockable or nonshockable), epinephrine use was associated with less D30 survival (odds ratio [OR] 0.508; 95% confidence interval [CI] 0.440-0.586] and OR 0.645; 95% CI 0.549-0.759, respectively). In shockable rhythms, on all outcomes, epinephrine use was deleterious. In nonshockable rhythms, no difference was observed regarding return of spontaneous circulation and survival at hospital admission. However, epinephrine use was associated with worse neurological prognosis (OR 0.646; 95% CI 0.549-0.759).

CONCLUSIONS

In shockable and nonshockable rhythms, epinephrine does not seem to have any benefit on D30 survival. These results underscore the need to perform further studies to define the optimal conditions for using epinephrine in patients with OHCA.

Nursery Assistants' Performance and Knowledge on Cardiopulmonary Resuscitation: Impact of Simulation-Based Training

Background: Child cardiac arrest is rare, but more frequent among infants, requiring immediate cardiopulmonary resuscitation (CPR). Many studies have reported that simulation-based training (SBT) increased CPR performance of healthcare providers. However, the CPR performance of laypeople using basic life support remains poorly known. The aim of this study was to assess nursery assistants' (non-healthcare providers) CPR performance and knowledge, before and after SBT. Methods: The study was carried out from January to June 2018 in the city of Poitiers, France. Two teaching sessions (T1 and T2) and two evaluation sessions (E1 and E2) were performed. Performance in infant CPR on a manikin at E1 and E2 were videotaped and assessed automatically with Resusci Baby QCPR® and a SimPad PLUS SkillReporter (QCPR Global Score and skills) and by an observer using an original CPR performance checklist (MCPR Global-Score and skills). Nursery assistant's CPR knowledge was assessed by a questionnaire at the beginning and the end of the session T1, E1, and E2. Results: Twenty-Seven nursery assistants over 30 contacted were included. There was an improvement between E1 and E2 in QCPR Global-Score (E1: 42.4 ± 23.6 vs. E2: 55.1 ± 23.7%, p = 0.032), MCPR Global-Score (E1: 50.0+11.9 vs. E2: 72.3+8.5%; p < 0.001) and theoretical knowledge with score (over 45) of 16.9+5.4 before T1 and 35.2+2.7 after E2, respectively (p < 0.001). The improvement mainly concerned QCPR and MCPR compression steps scores. MCPR Global-Score was strongly correlated to QCPR Global-Score (r = 0.61; p < 0.01) and predictive to CPR quality determined by QCPR Global-Score (AUC = 0.77; p < 0.01) with a high sensitivity and negative predictive values. Moreover, these improvements were maintained 2 months after training with no difference between scores obtained by the three groups 15, 30, or 60 days after simulation-based training session T2. Conclusion: SBT could significantly improve knowledge and skills in infant CPR management by nursery assistants especially for chest compression. CPR performance checklist appeared as an interesting tool to assess CPR performance quality.

Effect of bystander CPR initiated by a dispatch centre following out-of-hospital cardiac arrest on 30-day survival: Adjusted results from the French National Cardiac Arrest Registry

AIM

Cardiac arrest (CA) was considered irreversible until 1960, when basic cardiopulmonary resuscitation (CPR) was defined. CPR guidelines include early recognition of CA, rapid and effective CPR, effective defibrillation strategies and organized post-resuscitation to ensure a strengthening of the survival chain. Bystanders are the key to extremely early management, which is associated with the early medical care provided by EMS. This study aims to assess the prognosis of a bystander's cardiac CPR when it is initiated by the Dispatch Centre (DC).

METHODS

We included patients in 3 groups according to who initiated the CPR. The groups were matched according to multiple propensity partition methods. We presented our results in terms of 30-day survival and neurological prognosis.

RESULTS

85,634 patients were included. Statistical study focused on 18,185 patients once the exclusion criteria were applied. 12,743 (70.1%) are men and the average age is 70.1 years. Survival at D30 was 5.11% in the absence of CPR, 8.86% with bystander initiation and 7.35% with DC initiation (p < 0.001). Survival at D30 with favourable neurologic prognosis (CPC 1-2) was 76.30%, 83.69% and 82.82%, respectively. Our results show a 3.75% increase in the chance of survival at D30 if CPR was initiated by bystanders compared to patients for whom CPR was not initiated, a 2.25% increase in survival in the group that received from CPR initiated by the DC compared to the group that did not receive CPR.

CONCLUSIONS

Bystander CPR initiated by the DC represents a suitable option following out-of-hospital cardiac arrest.