Cardiac Arrest Resuscitation Evaluation in Los Angeles: CARE-LA

Early or late booster for basic life support skill for laypeople: a simulation-based randomized controlled trial

PURPOSE

Retention of skills and knowledge has been shown to be poor after resuscitation training. The effect of a "booster" is controversial and may depend on its timing. We compared the effectiveness of an early versus late booster session after Basic Life Support (BLS) training for skill retention at 4 months.

METHODS

We performed a single-blind randomized controlled trial in a simulation environment. Eligible participants were adult laypeople with no BLS training or practice in the 6 months prior to the study. We provided participants with formal BLS training followed by an immediate BLS skills post-test. We then randomized participants to one of three groups: control, early booster, or late booster. Based on their group allocation, participants attended a brief BLS refresher at either 3 weeks after training (early booster), at 2 months after training (late booster), or not at all (control). All participants underwent a BLS skills retention test at 4 months. We measured BLS skill performance according to the Heart and Stroke Foundation's skills testing checklist for adult CPR and the use of an automated external defibrillator.

RESULTS

A total of 80 laypeople were included in the analysis (control group, n = 28; early booster group, n = 23; late booster group, n = 29). The late booster group achieved better skill retention (mean difference in checklist score at retention compared to the immediate post-test = - 0.8 points out of 15, [95% CI - 1.7, 0.2], P = 0.10) compared to the early booster (- 1.3, [- 2.6, 0.0], P = 0.046) and control group (- 3.2, [- 4.7, - 1.8], P < 0.001).

CONCLUSION

A late booster session improves BLS skill retention at 4 months in laypeople.

TRIAL REGISTRATION NUMBER

NCT02998723.

Comparison of Emergency Medical Dispatch Systems for Performance of Telecommunicator-Assisted Cardiopulmonary Resuscitation Among 9-1-1 Callers With Limited English Proficiency

IMPORTANCE

Increasing bystander cardiopulmonary resuscitation (CPR) among racial/ethnic minority groups and culturally underserved populations is a key strategy in improving health care disparities in out-of-hospital cardiac arrest.

OBJECTIVE

To ascertain whether implementation of the Los Angeles Tiered Dispatch System (LA-TDS) was associated with improved performance of telecommunicator-assisted CPR (T-CPR) among 9-1-1 callers with limited English proficiency in the City of Los Angeles.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study compared emergency medical services-treated, nontraumatic out-of-hospital cardiac arrest calls using the Medical Priority Dispatch System (MPDS) from January 1 to March 31, 2014, with calls using LA-TDS from January 1 to March 31, 2015. Trained data abstractors evaluated all 9-1-1 audio recordings for the initiation of T-CPR and the elapsed time to predefined events. Data were analyzed between January and December 2017.

MAIN OUTCOMES AND MEASURES

The primary outcome was the prevalence of T-CPR among 9-1-1 callers with limited English proficiency for field-confirmed nontraumatic cardiac arrests. Additional outcomes included T-CPR among callers with English proficiency and the elapsed time until key events in the call.

RESULTS

Of the 1027 emergency medical services calls during the study periods, 597 met the inclusion criteria. A total of 289 calls (48%) were made using MPDS (263 callers with English proficiency, and 26 callers with limited English proficiency), and 308 calls (52%) were made using LA-TDS (273 callers with English proficiency, and 35 callers with limited English proficiency). No differences between MPDS and LA-TDS cohorts were found in age, sex, known comorbidities, arrest location (private vs public), or witnessed status. The prevalence of T-CPR among callers with limited English proficiency was significantly greater using LA-TDS (69%) vs MPDS (28%) (odds ratio [OR], 5.66; 95% CI, 1.79-17.85; P = .003). For callers with English proficiency, the prevalence of T-CPR improved from 55% using MPDS to 67% using LA-TDS (OR, 1.66; 95% CI, 1.15-2.41; P = .007). With LA-TDS, callers with limited English proficiency had a significant decrease in time to recognition of cardiac arrest (OR, 0.59; 95% CI, 0.41-0.84; P = .005) and dispatch of resources (OR, 0.71; 95% CI, 0.54-0.94; P = .02).

CONCLUSIONS AND RELEVANCE

The LA-TDS compared with MPDS was associated with increased performance of T-CPR for out-of-hospital cardiac arrests involving 9-1-1 callers with limited English proficiency. Further studies are needed in communities with a predominance of people with limited English proficiency to characterize bystander response, promote activation of the chain of survival, and clarify the precise elements of LA-TDS that can improve T-CPR performance.

The Effects of Early Bispectral Index to Predict Poor Neurological Function in Cardiac Arrest Patients: A Systematic Review and Meta-Analysis

The diagnostic performance of the bispectral index (BIS) to early predict neurological outcomes in patients achieving return of spontaneous circulation (ROSC) after cardiac arrest (CA) remained unclear. We searched PubMed, EMBASE, Scopus and CENTRAL for relevant studies through October 2019. Methodologic quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. Meta-analysis was performed using a linear mixed-effects model to the log-transformed data with a logistic distribution assumption. Bivariate meta-regression was performed to explore heterogeneity. In total, 13 studies with 999 CA adult patients were included. At the optimal threshold of 32, BIS obtained within 72 h of ROSC elicits a pooled sensitivity of 84.9% (95% confidence interval (CI), 71.1% to 92.7%), a pooled specificity of 85.9% (95% CI, 71.2% to 93.8%) and an area under the curve of 0.92. Moreover, a BIS cutoff < 12 yielded a pooled specificity of 95.0% (95% CI, 77.8% to 99.0%). In bivariate meta-regression, the timing of neurological outcome assessment, the adoption of targeted temperature management, and the administration of sedative agents or neuromuscular blocking agents (NMBA) were not identified as the potential source of heterogeneity. BIS retains good diagnostic performance during targeted temperature management (TTM) and in the presence of administrated sedative agents and NMBA. In conclusion, BIS can predict poor neurological outcomes early in patients with ROSC after CA with good diagnostic performance and should be incorporated into the neuroprognostication strategy algorithm.

Risk and ROSC - Legal implications of bystander CPR

BACKGROUND

Early bystander cardiopulmonary resuscitation (CPR) has been associated with better patient outcomes in cardiac arrest. Despite this, not all cases of cardiac arrest receive bystander intervention. Reasons for this gap include disparities in provision of bystander CPR between race, gender and age groups. Concern of legal liability for responders has also been described. We propose that bystanders are more likely to face litigation for lack of intervention compared to providing bystander CPR due to the presence of 'Good Samaritan' statutes in all 50 states. This review of the legal literature seeks to quantify the number of cases brought against bystanders in the US over the past 30 years and explore the reasons behind them.

METHODS

The Westlaw legal research database was searched for jury verdicts, settlements, and appellate opinions from all 50 states from 1989 to 2019 for personal injury or wrongful death lawsuits involving CPR. Of 506 cases manually reviewed by the authors, 170 were directly related to CPR. Case details including jurisdiction, location, date, plaintiff and defendant demographics, level of training of CPR provider, relationship to patient, motivation for the lawsuit, and case outcomes were recorded.

RESULTS

Our data show a significant difference in the number of cases of cases alleging battery versus negligence regarding provision of CPR. Of 170 cases, 167 were due to inadequate or untimely bystander CPR. Three cases alleging harm due to providing CPR were identified.

CONCLUSIONS

This study represents the largest single study of legal cases involving bystander CPR in the medical literature. The likelihood of litigation is significantly higher in cases with bystander CPR absent or delayed. The authors propose the inclusion of this data and reiteration of 'Good Samaritan' statutes in all 50 states during CPR training to reassure and encourage public response to cardiac arrests.

Outcomes following cardiopulmonary resuscitation in an emergency department of a low- and middle-income country

BACKGROUND

Cardiopulmonary resuscitation (CPR) is a key component of emergency care following cardiac arrest. A better understanding of factors that influence CPR outcomes and their prognostic implications would help guide care. A retrospective analysis of 800 adult patients that sustained an in- or out-of-hospital cardiac arrest and underwent CPR in the emergency department of a tertiary care facility in Karachi, Pakistan, between 2008 and 15 was conducted.

METHODS

Patient demographics, clinical history, and CPR characteristics data were collected. Logistic regression model was applied to assess predictors of return of spontaneous circulation and survival to discharge. Analysis was conducted using SPSS v.21.0.

RESULTS

Four hundred sixty-eight patients met the study's inclusion criteria, and overall return of spontaneous circulation and survival to discharge were achieved in 128 (27.4%) and 35 (7.5%) patients respectively. Mean age of patients sustaining return of spontaneous circulation was 52 years and that of survival to discharge was 49 years. The independent predictors of return of spontaneous circulation included age ≤ 49 years, witnessed arrest, ≤ 30 min interval between collapse-to-start, and 1-4 shocks given during CPR (aOR (95% CI) 2.2 (1.3-3.6), 1.9 (1.0-3.7), 14.6 (4.9-43.4), and 3.0 (1.4-6.4) respectively), whereas, age ≤ 52 years, bystander resuscitation, and initial rhythm documented (pulseless electrical activity and ventricular fibrillation) were independent predictors of survival to discharge (aOR (95% CI) 2.5 (0.9-6.5), 1.4 (0.5-3.8), 5.3 (1.5-18.4), and 3.1 (1.0-10.2) respectively).

CONCLUSION

Our study notes that while the majority of arrests occur out of the hospital, only a small proportion of those arrests receive on-site CPR, which is a key contributor to unfavorable outcomes in this group. It is recommended that effective pre-hospital emergency care systems be established in developing countries which could potentially improve post-arrest outcomes. Younger patients, CPR initiation soon after arrest, presenting rhythm of pulseless ventricular tachycardia and ventricular fibrillation, and those requiring up to four shocks to revive are more likely to achieve favorable outcomes.

Can a Software-Based Metronome Tool Enhance Compression Rate in a Realistic 911 Call Scenario Without Adversely Impacting Compression Depth for Dispatcher-Assisted CPR?

IntroductionImplementation of high-quality, dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) is critical to improving survival from out-of-hospital cardiac arrest (OHCA). However, despite some studies demonstrating the use of a metronome in a stand-alone setting, no research has yet demonstrated the effectiveness of a metronome tool in improving DA-CPR in the context of a realistic 911 call or using instructions that have been tested in real-world emergency calls.HypothesisUse of the metronome tool will increase the proportion of callers able to perform CPR within the target rate without affecting depth.

METHODS

The prospective, randomized, controlled study involved simulated 911 cardiac arrest calls made by layperson-callers and handled by certified emergency medical dispatchers (EMDs) at four locations in Salt Lake City, Utah USA. Participants were randomized into two groups. In the experimental group, layperson-callers received CPR pre-arrival instructions with metronome assistance. In the control group, layperson-callers received only pre-arrival instructions. The primary outcome measures were correct compression rate (counts per minute [cpm]) and depth (mm).

RESULTS

A total of 148 layperson-callers (57.4% assigned to experimental group) participated in the study. There was a statistically significant association between the number of participants who achieved the target compression rate and experimental study group (P=.003), and the experimental group had a significantly higher median compression rate than the control group (100 cpm and 89 cpm, respectively; P=.013). Overall, there was no significant correlation between compression rate and depth.

CONCLUSION

An automated software metronome tool is effective in getting layperson-callers to achieve the target compression rate and compression depth in a realistic DA-CPR scenario.Scott G, Barron T, Gardett I, Broadbent M, Downs H, Devey L, Hinterman EJ, Clawson J, Olola C. Can a software-based metronome tool enhance compression rate in a realistic 911 call scenario without adversely impacting compression depth for dispatcher-assisted CPR? Prehosp Disaster Med. 2018;33(4):399-405.

Prognostication in Anoxic Brain Injury

Cardiac arrest is a common cause of coma with frequent poor outcomes. Palliative medicine teams are often called upon to discuss the scope of treatment and future care in cases of anoxic brain injury. Understanding prognostic tools in this setting would help medical teams communicate more effectively with patients’ families and caregivers and may promote improved quality of life overall. This article reviews multiple tools that are useful in determining outcomes in the setting of postarrest anoxic brain injury.

[Drug Repositioning Research Utilizing a Large-scale Medical Claims Database to Improve Survival Rates after Cardiopulmonary Arrest]

 Approximately 100000 people suffer cardiopulmonary arrest in Japan every year, and the aging of society means that this number is expected to increase. Worldwide, approximately 100 million develop cardiac arrest annually, making it an international issue. Although survival has improved thanks to advances in cardiopulmonary resuscitation, there is a high rate of postresuscitation encephalopathy after the return of spontaneous circulation, and the proportion of patients who can return to normal life is extremely low. Treatment for postresuscitation encephalopathy is long term, and if sequelae persist then nursing care is required, causing immeasurable economic burdens as a result of ballooning medical costs. As at present there is no drug treatment to improve postresuscitation encephalopathy as a complication of cardiopulmonary arrest, the development of novel drug treatments is desirable. In recent years, new efficacy for existing drugs used in the clinical setting has been discovered, and drug repositioning has been proposed as a strategy for developing those drugs as therapeutic agents for different diseases. This review describes a large-scale database study carried out following a discovery strategy for drug repositioning with the objective of improving survival rates after cardiopulmonary arrest and discusses future repositioning prospects.

A Prospective Investigation into the Epidemiology of In-Hospital Cardiopulmonary Resuscitation Using the International Utstein Reporting Style

Introduction

The Utstein template has been used to guide the assessment and study of cardiopulmonary resuscitation (CPR) in many countries. This article used the Utstein templates for cardiac arrest and resuscitation registries to evaluate outcomes of CPR at Hainan Provincial People's Hospital (HPPH), China.

Methods

A prospective observational study using Utstein CPR registry form to evaluate the epidemiological characteristics and outcomes of 511 resuscitation cases in the emergency department, HPPH.

Results

A total of 511 CPR patients registered were studied. Higher cardiac arrest rates were observed for the group of patients who were 40-70 years old. In preexisting chronic diseases, cardiovascular diseases (190, 37.2%) cerebrovascular diseases (48, 9.4%) and respiratory diseases (39, 7.6%) were common in the recruited patients. (173, 33.9%) of the cardiac arrest patients had underlying cardiac causes, of which 109 (21.3%) had acute myocardial infarct (AMI). Eighty (15.7%) patients had ventricular fibrillation as the first witnessed arrest rhythm. The return of spontaneous circulation (ROSC) and survival to discharge rates were 47.0% and 13.5% in the in-hospital cardiac arrest (IHCA) group but 16.7% and 4.7% in out-of-hospital cardiac arrest (OHCA) group (p<0.01) respectively.

Conclusions

This study indicated that the cardiovascular diseases, cerebrovascular diseases, and respiratory diseases were the most common preexisting chronic diseases. Myocardial infarct, stroke and trauma were the most common precipitation cause of cardiac arrest in the recruited patients. The rate of ROSC and survival to discharge for the patients with IHCA were higher than the ones with OHCA, but figures were still low. (Hong Kong j.emerg.med. 2011;18:391-396)

Continuous chest compression versus interrupted chest compression for cardiopulmonary resuscitation of non-asphyxial out-of-hospital cardiac arrest

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is a major cause of death worldwide. Cardiac arrest can be subdivided into asphyxial and non asphyxial etiologies. An asphyxia arrest is caused by lack of oxygen in the blood and occurs in drowning and choking victims and in other circumstances. A non asphyxial arrest is usually a loss of functioning cardiac electrical activity. Cardiopulmonary resuscitation (CPR) is a well-established treatment for cardiac arrest. Conventional CPR includes both chest compressions and 'rescue breathing' such as mouth-to-mouth breathing. Rescue breathing is delivered between chest compressions using a fixed ratio, such as two breaths to 30 compressions or can be delivered asynchronously without interrupting chest compression. Studies show that applying continuous chest compressions is critical for survival and interrupting them for rescue breathing might increase risk of death. Continuous chest compression CPR may be performed with or without rescue breathing.

OBJECTIVES

To assess the effects of continuous chest compression CPR (with or without rescue breathing) versus conventional CPR plus rescue breathing (interrupted chest compression with pauses for breaths) of non-asphyxial OHCA.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; Issue 1 2017); MEDLINE (Ovid) (from 1985 to February 2017); Embase (1985 to February 2017); Web of Science (1985 to February 2017). We searched ongoing trials databases including controlledtrials.com and clinicaltrials.gov. We did not impose any language or publication restrictions.

SELECTION CRITERIA

We included randomized and quasi-randomized studies in adults and children suffering non-asphyxial OHCA due to any cause. Studies compared the effects of continuous chest compression CPR (with or without rescue breathing) with interrupted CPR plus rescue breathing provided by rescuers (bystanders or professional CPR providers).

DATA COLLECTION AND ANALYSIS

Two authors extracted the data and summarized the effects as risk ratios (RRs), adjusted risk differences (ARDs) or mean differences (MDs). We assessed the quality of evidence using GRADE.

MAIN RESULTS

We included three randomized controlled trials (RCTs) and one cluster-RCT (with a total of 26,742 participants analysed). We identified one ongoing study. While predominantly adult patients, one study included children. Untrained bystander-administered CPRThree studies assessed CPR provided by untrained bystanders in urban areas of the USA, Sweden and the UK. Bystanders administered CPR under telephone instruction from emergency services. There was an unclear risk of selection bias in two trials and low risk of detection, attrition, and reporting bias in all three trials. Survival outcomes were unlikely to be affected by the unblinded design of the studies.We found high-quality evidence that continuous chest compression CPR without rescue breathing improved participants' survival to hospital discharge compared with interrupted chest compression with pauses for rescue breathing (ratio 15:2) by 2.4% (14% versus 11.6%; RR 1.21, 95% confidence interval (CI) 1.01 to 1.46; 3 studies, 3031 participants).One trial reported survival to hospital admission, but the number of participants was too low to be certain about the effects of the different treatment strategies on survival to admission(RR 1.18, 95% CI 0.94 to 1.48; 1 study, 520 participants; moderate-quality evidence).There were no data available for survival at one year, quality of life, return of spontaneous circulation or adverse effects.There was insufficient evidence to determine the effect of the different strategies on neurological outcomes at hospital discharge (RR 1.25, 95% CI 0.94 to 1.66; 1 study, 1286 participants; moderate-quality evidence). The proportion of participants categorized as having good or moderate cerebral performance was 11% following treatment with interrupted chest compression plus rescue breathing compared with 10% to 18% for those treated with continuous chest compression CPR without rescue breathing. CPR administered by a trained professional In one trial that assessed OHCA CPR administered by emergency medical service professionals (EMS) 23,711 participants received either continuous chest compression CPR (100/minute) with asynchronous rescue breathing (10/minute) or interrupted chest compression with pauses for rescue breathing (ratio 30:2). The study was at low risk of bias overall.After OHCA, risk of survival to hospital discharge is probably slightly lower for continuous chest compression CPR with asynchronous rescue breathing compared with interrupted chest compression plus rescue breathing (9.0% versus 9.7%) with an adjusted risk difference (ARD) of -0.7%; 95% CI (-1.5% to 0.1%); moderate-quality evidence.There is high-quality evidence that survival to hospital admission is 1.3% lower with continuous chest compression CPR with asynchronous rescue breathing compared with interrupted chest compression plus rescue breathing (24.6% versus 25.9%; ARD -1.3% 95% CI (-2.4% to -0.2%)).Survival at one year and quality of life were not reported.Return of spontaneous circulation is likely to be slightly lower in people treated with continuous chest compression CPR plus asynchronous rescue breathing (24.2% versus 25.3%; -1.1% (95% CI -2.4 to 0.1)), high-quality evidence.There is high-quality evidence of little or no difference in neurological outcome at discharge between these two interventions (7.0% versus 7.7%; ARD -0.6% (95% CI -1.4 to 0.1).Rates of adverse events were 54.4% in those treated with continuous chest compressions plus asynchronous rescue breathing versus 55.4% in people treated with interrupted chest compression plus rescue breathing compared with the ARD being -1% (-2.3 to 0.4), moderate-quality evidence).

AUTHORS' CONCLUSIONS

Following OHCA, we have found that bystander-administered chest compression-only CPR, supported by telephone instruction, increases the proportion of people who survive to hospital discharge compared with conventional interrupted chest compression CPR plus rescue breathing. Some uncertainty remains about how well neurological function is preserved in this population and there is no information available regarding adverse effects.When CPR was performed by EMS providers, continuous chest compressions plus asynchronous rescue breathing did not result in higher rates for survival to hospital discharge compared to interrupted chest compression plus rescue breathing. The results indicate slightly lower rates of survival to admission or discharge, favourable neurological outcome and return of spontaneous circulation observed following continuous chest compression. Adverse effects are probably slightly lower with continuous chest compression.Increased availability of automated external defibrillators (AEDs), and AED use in CPR need to be examined, and also whether continuous chest compression CPR is appropriate for paediatric cardiac arrest.

Adult out-of-hospital cardiac arrest in philadelphia from 2008-2012: An epidemiological study

BACKGROUND

Wide variation in out-of-hospital cardiac arrest (OHCA) survival has been reported, with low survival in urban settings. We sought to describe the epidemiology of OHCA in Philadelphia, Pennsylvania, the fifth largest U.S. city, and identify potential areas for targeted interventions to improve survival.

METHODS AND RESULTS

Retrospective chart review of adult, non-traumatic, OHCA occurring in Philadelphia between 2008 and 2012. We determined incidence and epidemiological factors including: demographics, initial cardiac rhythm, bystander cardiopulmonary resuscitation, automated external defibrillator use, return of spontaneous circulation and 30-day survival. 5198 cases of adult, non-traumatic OHCA were identified. The incidence was 81.5/100,000. The majority of cases occurred in a residence (76.2%); 30.4% were witnessed events; the initial cardiac rhythm was pulseless ventricular tachycardia or ventricular fibrillation in 6.2% of cases, pulseless electrical activity in 21.0%, asystole in 38.3% and was unknown or undocumented in the remaining 34.5%. Multivariate logistic regression analysis demonstrated increased 30-day survival with younger age, shockable cardiac rhythms, and daytime arrest. 30-day survival was 8.1% for EMS-assessed patients and 8.6% for EMS-transported patients.

CONCLUSIONS

Philadelphia's reported incidence is consistent with urban settings although the survival rate is higher than other urban centers.

Transplantation with hypoxia-preconditioned mesenchymal stem cells suppresses brain injury caused by cardiac arrest-induced global cerebral ischemia in rats

Cardiac arrest-induced global cerebral ischemia is a main cause of neurological dysfunction in emergency medicine. Transplantation with bone marrow mesenchymal stem cells (MSCs) has been used in stroke models to repair the ischemic brain injury, but it is little studied in models with global cerebral ischemia. In the present study, a hypoxia precondition was used to improve the efficacy of MSC transplantation, given the low survival and migration rates and limited differentiation capacities of MSCs. We found that hypoxia can increase the expansion and migration of MSCs by activating the PI3K/AKT and hypoxia-inducible factor-1α/CXC chemokine receptor-4 pathways. By using a cardiac arrest-induced global cerebral ischemic model in rats, we found that transplantation of hypoxia-preconditioned MSCs promoted the migration and integration of MSCs and decreased neuronal death and inflammation in the ischemic cortex. © 2017 Wiley Periodicals, Inc.

Retention of Basic Life Support in Laypeople: Mastery Learning vs. Time-based Education

OBJECTIVE

To compare the effectiveness of a mastery learning (ML) versus a time-based (TB) BLS course for the acquisition and retention of BLS knowledge and skills in laypeople.

METHODS

After ethics approval, laypeople were randomized to a ML or TB BLS course based on the American Heart Association (AHA) Heartsaver course. In the ML group, subjects practiced and received feedback at six BLS stations until they reached a pre-determined level of performance. The TB group received a standard AHA six-station BLS course. All participants took the standard in-course BLS skills test at the end of their course. BLS skills and knowledge were tested using a high-fidelity scenario and knowledge questionnaire upon course completion (immediate post-test) and after four months (retention test). Video recorded scenarios were assessed by two blinded, independent raters using the AHA skills checklist.

RESULTS

Forty-three subjects were included in analysis (23ML;20TB). For primary outcome, subjects' performance did not change after four months, regardless of the teaching modality (TB from (median[IQR]) 8.0[6.125;8.375] to 8.5[5.625;9.0] vs. ML from 8.0[7.0;9.0] to 7.0[6.0;8.0], p = 0.12 for test phase, p = 0.21 for interaction between effect of teaching modality and test phase). For secondary outcomes, subjects acquired knowledge between pre- and immediate post-tests (p < 0.005), and partially retained the acquired knowledge up to four months (p < 0.005) despite a decrease between immediate post-test and retention test (p = 0.009), irrespectively of the group (p = 0.59) (TB from 63.3[48.3;73.3] to 93.3[81.7;100.0] and then 93.3[81.7;93.3] vs. ML from 60.0[46.7;66.7] to 93.3[80.0;100.0] and then 80.0[73.3;93.3]). Regardless of the group after 4 months, chest compression depth improved (TB from 39.0[35.0;46.0] to 48.5[40.25;58.0] vs. ML from 40.0[37.0;47.0] to 45.0[37.0;52.0]; p = 0.012), but not the rate (TB from 118.0[114.0;125.0] to 120.5[113.0;129.5] vs. ML from 119.0[113.0;130.0] to 123.0[102.0;132.0]; p = 0.70). All subjects passed the in-course BLS skills test. Pass/fail rates were poor in both groups at both the simulated immediate post-test (ML = 1/22;TB = 0/20; p = 0.35) and retention test (ML pass/fail = 1/22, TB pass/fail = 0/20; p = 0.35). The ML course was slightly longer than the TB course (108[94;117] min vs. 95[89;102] min; p = 0.003).

CONCLUSIONS

There was no major benefit of a ML compared to a TB BLS course for the acquisition and four-month retention of knowledge or skills among laypeople.

Survival After Ventricular Fibrillation Cardiac Arrest in the Sao Paulo Metropolitan Subway System: First Successful Targeted Automated External Defibrillator (AED) Program in Latin America

BACKGROUND

Targeted automated external defibrillator (AED) programs have improved survival rates among patients who have an out-of-hospital cardiac arrest (OHCA) in US airports, as well as European and Japanese railways. The Sao Paulo (Brazil) Metro subway carries 4.5 million people per day. A targeted AED program was begun in the Sao Paulo Metro with the objective to improve survival from cardiac arrest.

METHODS AND RESULTS

A prospective, longitudinal, observational study of all cardiac arrests in the Sao Paulo Metro was performed from September 2006 through November 2012. This study focused on cardiac arrest by ventricular arrhythmias, and the primary endpoint was survival to hospital discharge with minimal neurological impairment. A total of 62 patients had an initial cardiac rhythm of ventricular fibrillation. Because no data on cardiac arrest treatment or outcomes existed before beginning this project, the first 16 months of the implementation was used as the initial experience and compared with the subsequent 5 years of full operation. Return of spontaneous circulation was not different between the initial 16 months and the subsequent 5 years (6 of 8 [75%] vs. 39 of 54 [72%]; P=0.88). However, survival to discharge was significantly different once the full program was instituted (0 of 8 vs. 23 of 54 [43%]; P=0.001).

CONCLUSIONS

Implementation of a targeted AED program in the Sao Paulo Metro subway system saved lives. A short interval between arrest and defibrillation was key for good long-term, neurologically intact survival. These results support strategic expansion of targeted AED programs in other large Latin American cities.

A multiple linear regression analysis of factors affecting the simulated Basic Life Support (BLS) performance with Automated External Defibrillator (AED) in Flemish lifeguards

BACKGROUND

Research investigating lifeguards' performance of Basic Life Support (BLS) with Automated External Defibrillator (AED) is limited.

AIM

Assessing simulated BLS/AED performance in Flemish lifeguards and identifying factors affecting this performance.

METHODS

Six hundred and sixteen (217 female and 399 male) certified Flemish lifeguards (aged 16-71 years) performed BLS with an AED on a Laerdal ResusciAnne manikin simulating an adult victim of drowning. Stepwise multiple linear regression analysis was conducted with BLS/AED performance as outcome variable and demographic data as explanatory variables.

RESULTS

Mean BLS/AED performance for all lifeguards was 66.5%. Compression rate and depth adhered closely to ERC 2010 guidelines. Ventilation volume and flow rate exceeded the guidelines. A significant regression model, F(6, 415)=25.61, p<.001, ES=.38, explained 27% of the variance in BLS performance (R2=.27). Significant predictors were age (beta=-.31, p<.001), years of certification (beta=-.41, p<.001), time on duty per year (beta=-.25, p<.001), practising BLS skills (beta=.11, p=.011), and being a professional lifeguard (beta=-.13, p=.029). 71% of lifeguards reported not practising BLS/AED.

DISCUSSION

Being young, recently certified, few days of employment per year, practising BLS skills and not being a professional lifeguard are factors associated with higher BLS/AED performance.

CONCLUSION

Measures should be taken to prevent BLS/AED performances from decaying with age and longer certification. Refresher courses could include a formal skills test and lifeguards should be encouraged to practise their BLS/AED skills.

Inaccuracy of patient care reports for identification of critical resuscitation events during out-of-hospital cardiac arrest

OBJECTIVE

Out-of-hospital cardiac arrest (OHCA) is a leading cause of mortality in the United States. We sought to evaluate the accuracy of the patient care report (PCR) for detection of 2 clinically important events: return of spontaneous circulation (ROSC) and rearrest (RA).

METHODS

We used defibrillator recordings and PCRs for Emergency Medical Services-treated OHCA collected by the Resuscitation Outcomes Consortium's Pittsburgh site from 2006 to 2008 and 2011 to 2012. Defibrillator data included electrocardiogram rhythm tracing, chest compression measurement, and audio voice recording. Sensitivity analysis was performed by comparing the accuracy of the PCR to detect the presence and number of ROSC and RA events to integrated defibrillator data.

RESULTS

In the 158 OHCA cases, there were 163 ROSC events and 53 RA events. The sensitivity of PCRs to identify all ROSC events was 85% (confidence interval [CI], .795-.905); to identify primary ROSC events, it was 85% (CI, .793-.907); and to identify secondary ROSC events, it was 78% (CI, .565-.995). The sensitivity of PCRs to identify the presence of all RA events was .60 (CI, .469-.731); to identify primary RA events, it was 71% (CI, .578-.842); and to identify secondary RA events, it was 0. Of the 32 RA incidents captured by the PCR, only 15 (47%) correctly identified the correct lethal arrhythmia.

CONCLUSIONS

We found that PCRs are not a reliable source of information for assessing the presence of ROSC and post-RA electrocardiogram rhythm. For quality control and research purposes, medical providers should consider augmenting data collection with continuous defibrillator recordings before making any conclusions about the occurrence of critical resuscitation events.

Outcome of out-of-hospital cardiac arrests in Beijing, China

AIM

The purpose of this study was to assess the outcome of out-of-hospital cardiac arrests (OHCAs) in Beijing, China.

METHODS

In this prospective study, data were collected according to the Utstein style on all cases of OHCA that occurred between January and December 2012 in urban areas covered by Beijing Emergency Medical Services (EMS). The cases were followed-up for 1 year.

RESULTS

Out of the 9897 OHCAs recorded, cardiopulmonary resuscitation (CPR) was initiated in 2421 patients (24.4%). Among the CPR-receivers (n=2421), 1804 patients (74.5%) had collapsed at home, while 375 patients (15.5%) at a public place. The average time interval from call to EMS arrival at the collapse location was 16 min (range, 4-43 min). Of the 1693 OHCA cases with cardiac aetiology, 1246 cases (73.6%) were witnessed, and basic CPR was performed by bystanders before arrival of the EMS personnel in 193 patients (11.4%). Of the OHCAs with cardiac aetiology, 1054 patients (62.3%) had asystole, 131 patients (7.7%) had shockable rhythms, restoration of spontaneous circulation was achieved in 85 patients (5.0%), 71 patients (4.2%) were admitted to the hospital alive, and of the 22 patients (1.3%) who were discharged alive, 17 patients (1%) had good neurological outcomes. At 1 year post-OHCA, 17 patients were alive.

CONCLUSION

In the urban areas of Beijing with EMS services, survival rate after OHCA was unsatisfactory. Improvements are required in every link of the 'chain of survival'.

Pharmaco-proteomics opportunities for individualizing neurovascular treatment

Neurovascular disease often involves multi-organ system injury. For example, patent foramen ovale (PFO) related ischemic strokes involve not just the brain, but also the heart, the lung, and the peripheral vascular circulation. For higher-risk but high-reward systemic therapy (e.g., thrombolytics, therapeutic hypothermia (TH), PFO closure) to be implemented safely, very careful patient selection and close monitoring of disease progression and therapeutic efficacy are imperative. For example, more than a decade after the approval of therapeutic hypothermic and intravenous thrombolysis treatments, they both remain extremely under-utilized, in part due to lack of clinical tools for patient selection or to follow therapeutic efficacy. Therefore, in understanding the complexity of the global effects of clinical neurovascular diseases and their therapies, a systemic approach may offer a unique perspective and provide tools with clinical utility. Clinical proteomic approaches may be promising to monitor systemic changes in complex multi-organ diseases - especially where the disease process can be 'sampled' in clinically accessible fluids such as blood, urine, and CSF. Here, we describe a 'pharmaco-proteomic' approach to three major challenges in translational neurovascular research directly at bedside - in order to better stratify risk, widen therapeutic windows, and explore novel targets to be validated at the bench - (i) thrombolytic treatment for ischemic stroke, (ii) therapeutic hypothermia for post-cardiac arrest syndrome, and (iii) treatment for PFO related paradoxical embolic stroke. In the future, this clinical proteomics approach may help to improve patient selection, ensure more precise clinical phenotyping for clinical trials, and individualize patient treatment.

Expanding the role of percutaneous coronary intervention in patients resuscitated from cardiac arrest

Special attention to post-cardiac arrest management is important to long-term survival and favorable neurological outcome in patients resuscitated from cardiac arrest. The use of emergent percutaneous coronary intervention in resuscitated patients presenting with ST-segment elevation myocardial infarction has long been considered an appropriate approach for coronary revascularization. Recent evidence suggests that other subsets of patients, namely, post-cardiac arrest patients without ST-segment elevation myocardial infarction, may benefit from immediate percutaneous coronary intervention following resuscitation. These findings could eventually have important implications for the care of resuscitated patients, including transportation of resuscitated patients to appropriate cardiac interventional facilities, access to treatment modalities such as therapeutic hypothermia, and coordinated care with cardiac catheterization laboratories.

Delayed high-quality CPR does not improve outcomes

AIM OF STUDY

The quality of cardiopulmonary resuscitation (CPR) is an important factor in the outcome of cardiac arrest. Our objective was to compare outcomes following either immediate low-quality (LQ) CPR or delayed high-quality (HQ) CPR. We hypothesized that delayed HQ CPR will improve the outcomes of CPR in comparison to immediately performing LQ CPR.

METHODS

Eighteen Sprague-Dawley rats were randomized into two groups: (1) Delayed HQ CPR (HQ group, n = 9). (2) Immediate LQ CPR (LQ group, n = 9). Ventricular fibrillation (VF) was induced and untreated for 8 mins. CPR was immediately performed in LQ group for 5 mins. Compression depth was set at 70% of the "optimal compression depth". VF was untreated for an additional 5 mins in HQ group. HQ CPR was started together with ventilation (100% oxygen) and external hypothermia for 8 mins in both groups. The "optimal compression depth" was approximately 30% of the anteroposterior chest diameter. Epinephrine was administrated 3 mins prior to defibrillation attempt. Restoration of spontaneous circulation, postresuscitation myocardial function and survival time were monitored.

RESULTS

All animals in the LQ group and 7 of 9 animals in the HQ group were resuscitated. Myocardial function, including ejection fraction and cardiac output was better in the LQ group than in the HQ group (p < 0.05) and survival time was longer in the LQ group (p < 0.05).

CONCLUSION

The outcomes after immediate LQ CPR, were better than those after delayed HQ CPR in this rat model of cardiac arrest and resuscitation.

Mobile phone-assisted basic life support augmented with a metronome

BACKGROUND

Basic life support (BLS) performed by lay rescuers is poor. We developed software for mobile phones augmented with a metronome to improve BLS.

STUDY OBJECTIVES

To assess BLS in lay rescuers with or without software assistance.

METHODS

Medically untrained volunteers were randomized to run through a cardiac arrest scenario with ("assisted BLS") or without ("non-assisted BLS") the aid of a BLS software program installed on a mobile phone.

RESULTS

Sixty-four lay rescuers were enrolled in the "assisted BLS" and 77 in the "non-assisted BLS" group. The "assisted BLS" when compared to the "non-assisted BLS" group, achieved a higher overall score (19.2 ± 7.5 vs. 12.9 ± 5.7 credits; p < 0.001). Moreover, the "assisted BLS" when compared to the "non-assisted" group checked (64% vs. 27%) and protected themselves more often from environmental risks (70% vs. 39%); this group also called more often for help (56% vs. 27%), opened the upper airway (78% vs. 16%), and had more correct chest compressions rates (44% ± 38% vs. 14% ± 28%; all p < 0.001). However, the "assisted BLS" when compared to the "non-assisted BLS" group, was slower in calling the dispatch center (113.6 ± 86.4 vs. 54.1 ± 45.1 s; p < 0.001) and starting chest compressions (165.3 ± 93.3 vs. 87.1 ± 53.2 s; p < 0.001).

CONCLUSIONS

"Assisted BLS" augmented by a metronome resulted in a higher overall score and a better chest compression rate when compared to "non-assisted BLS." However, in the "assisted BLS" group, time to call the dispatch center and to start chest compressions was longer. In both groups, lay persons did not ventilate satisfactorily during this cardiac arrest scenario.

Translation of evidence-based clinical standards into a new prehospital resuscitation policy in Los Angeles County

OBJECTIVE

To translate a set of evidence-based clinical standards designed to allow paramedics to forego unnecessary and potentially harmful resuscitation attempts into a feasible new policy.

DATA SOURCES/SETTING

Policy documents, meeting minutes, and personal communications between a large urban Emergency Medical Services (EMS) agency serving all of Los Angeles County (LAC) and a research group were reviewed over 12 months.

STUDY DESIGN

LAC EMS and University of California, Los Angeles (UCLA) formed a partnership (the EMS-UCLA Collaborative) to develop and translate the standards into new EMS protocols. Clinical indicators considered appropriate and feasible by an expert panel were submitted to the agency for inclusion in the new policy.

FINDINGS

The Collaborative submitted the results to the LAC EMS Commission and a physician advisory group for review. Of the 41 indicators approved by the expert panel, 22 would have resulted in changes to the current policy. All six involved asking family members about or honoring written and verbal Do Not Attempt Resuscitate requests, but only 4 of the 16 indicators based on clinical characteristics were included in the new policy. Ultimately, 10 of the 22 indicators that would have changed policy were approved and implemented.

CONCLUSIONS

By collaboration, a large EMS agency and a research team were able to develop and implement a revised resuscitation policy within 1 year.

Incidence and mortality of acute myocardial infarction. A population-based study including patients with out-of-hospital cardiac arrest

The in-hospital mortality rate of acute myocardial infarction (AMI) is improving. In Japan, little information exists concerning the incidence and mortality of AMI. Therefore, our population-based analysis examined the incidence and mortality rate in AMI cases in individuals that lived in the Matsumoto region in 2002. We studied 169 AMI patients who were admitted within 14 days after a non-out-of-hospital cardiac arrest (non-OHCA group) and 63 patients with an AMI-related out-of-hospital cardiac arrest (OHCA group). The in-hospital mortality rate of the non-OHCA group was 9.5% (reperfusion therapy [+] 3.4%, [-] 22.7%, P < 0.0001). The rate of return of spontaneous circulation and the survival rate were 21% and 1.6%, respectively, in the OHCA group. The incidence of AMI in the non-OHCA and OHCA groups combined was 55.2 to 63.1 events/100,000 people annually and the mean age of AMI patients was 70 ± 13 years. The population-based mortality rate of AMI was 34% to 42%. The mortality rate of AMI remains high, and most deaths occur outside of the hospital. Prehospital care may lower the mortality rate of AMI.

End-Tidal CO2 as a Predictor of Survival in Out-of-Hospital Cardiac Arrest

Objective: The objective of this study was to evaluate initial end-tidal CO2 (EtCO2) as a predictor of survival in out-of-hospital cardiac arrest.

Methods: This was a retrospective study of all adult, non-traumatic, out-of-hospital, cardiac arrests during 2006 and 2007 in Los Angeles, California. The primary outcome variable was attaining return of spontaneous circulation (ROSC) in the field. All demographic information was reviewed and logistic regression analysis was performed to determine which variables of the cardiac arrest were significantly associated with ROSC.

Results: There were 3,121 cardiac arrests included in the study, of which 1,689 (54.4%) were witnessed, and 516 (16.9%) were primary ventricular fibrillation (VF). The mean initial EtCO2 was 18.7 (95%CI = 18.2–19.3) for all patients. Return of spontaneous circulation was achieved in 695 patients (22.4%) for which the mean initial EtCO2 was 27.6 (95%CI = 26.3–29.0). For patients who failed to achieve ROSC, the mean EtCO2 was 16.0 (95%CI = 15.5–16.5). The following variables were significantly associated with achieving ROSC: witnessed arrest (OR = 1.51; 95%CI = 1.07–2.12); initial EtCO2 >10 (OR = 4.79; 95%CI = 3.10–4.42); and EtCO2 dropping <25% during the resuscitation (OR = 2.82; 95%CI = 2.01–3.97).

The combination of male gender, lack of bystander cardiopulmonary resuscitation, unwitnessed collapse, non-vfib arrest, initial EtCO2 ≤10 and EtCO2 falling > 25% was 97% predictive of failure to achieve ROSC.

Conclusions: An initial EtCO2 >10 and the absence of a falling EtCO2 >25% from baseline were significantly associated with achieving ROSC in out-of-hospital cardiac arrest. These additional variables should be incorporated in termination of resuscitation algorithms in the prehospital setting.

A model for the association of the call volume and the unavailable-for-response interval on the delayed ambulance response for out-of-hospital cardiac arrest using a geographic information system

BACKGROUND

An optimal ambulance response interval is desirable for emergency medical services (EMS) operations. Arriving on scene within a treatment time window is often delayed for many reasons, including overwhelming call volume.

OBJECTIVE

To determine whether an association exists between the ambulance call volume (ACV), the unavailable-for-response (UFR) interval, and the delayed ambulance response for out-of-hospital cardiac arrest (OHCA) patients.

METHODS

This was a retrospective observational study conducted in Seoul, Republic of Korea. The EMS ambulance logs from the metropolitan city's 22 EMS agencies, from January 1, 2006, to June 30, 2007, were obtained from the National Emergency Management Agency. These data included patient demographics and call location addresses. The addresses of the call locations and ambulance stations were geocoded and configured with a polygon expressing the optimal coverage areas in which an ambulance could travel within 4 minutes from their base station. The median ACV and mean UFR interval of each EMS agency were calculated. An actual response time interval greater than 4 minutes compared with the optimal coverage area was defined as a suboptimal response. Potential influencing factors on suboptimal response were analyzed using a multivariate logistic regression model to calculated the odds ratio (OR) and 95% confidence interval (95% CI).

RESULTS

Geocoding was successful for 255,961 calls, and 3,644 cardiac arrests occurred within the configured optimal response coverage areas. The response rate intervals for cardiac arrest patients, however, were optimal in only 22.6% of calls. Influencing factors for suboptimal response (occurring in 77.4% of the cases) were the median ACV and the mean UFR interval of each EMS agency. When the median ACV was seven or more, the OR of suboptimal response was 1.407 (1.142-1.734). If the mean UFR interval was 55 minutes or more, the OR for suboptimal response was 1.770 (1.345-2.329).

CONCLUSION

The ambulance response time intervals in this study setting were associated with EMS agencies with higher ACVs and longer UFR intervals.

The association between prehospital endotracheal intubation attempts and survival to hospital discharge among out-of-hospital cardiac arrest patients

OBJECTIVES

The benefit of prehospital endotracheal intubation (ETI) among individuals experiencing out-of-hospital cardiac arrest (OOHCA) has not been fully examined. The objective of this study was to determine if prehospital ETI attempts were associated with return of spontaneous circulation (ROSC) and survival to discharge among individuals experiencing OOHCA.

METHODS

This retrospective study included individuals who experienced a medical cardiac arrest between July 2006 and December 2008 and had resuscitation efforts initiated by paramedics from Mecklenburg County, North Carolina. Outcome variables were prehospital ROSC and survival to hospital discharge, while the primary independent variable was the number of prehospital ETI attempts.

RESULTS

There were 1,142 cardiac arrests included in the analytic data set. Prehospital ROSC occurred in 299 individuals (26.2%). When controlling for initial arrest rhythm and other confounding variables, individuals with no ETI attempted were 2.33 (95% confidence interval [CI] = 1.63 to 3.33) times more likely to have ROSC compared to those with one successful ETI attempt. Of the 299 individuals with prehospital ROSC, 118 (39.5%) were subsequently discharged alive from the hospital. Individuals having no ETI were 5.46 (95% CI = 3.36 to 8.90) times more likely to be discharged from the hospital alive compared to individuals with one successful ETI attempt.

CONCLUSIONS

Results from these analyses suggest a negative association between prehospital ETI attempts and survival from OOHCA. In this study, the individuals most likely to have prehospital ROSC and survival to hospital discharge were those who did not have a reported ETI attempt. Further comparative research should assess the potential causes of the demonstrated associations.

Advanced airway management does not improve outcome of out-of-hospital cardiac arrest

BACKGROUND

The goal of out-of-hospital endotracheal intubation (ETI) is to reduce mortality and morbidity for patients with airway and ventilatory compromise. Yet several studies, mostly involving trauma patients, have demonstrated similar or worse neurologic outcomes and survival-to-hospital discharge rates after out-of-hospital ETI. To date, there is no study comparing out-of-hospital ETI to bag-valve-mask (BVM) ventilation for the outcome of survival to hospital discharge among nontraumatic adult out-of-hospital cardiac arrest (OOHCA) patients.

OBJECTIVES

The objective was to compare survival to hospital discharge among adult OOHCA patients receiving ETI to those managed with BVM.

METHODS

In this retrospective cohort study, the records of all OOHCA patients presenting to a municipal teaching hospital from November 1, 1994, through June 30, 2008, were reviewed. The type of field airway provided, age, sex, race, rhythm on paramedic arrival, presence of bystander cardiopulmonary resuscitation (CPR), whether the arrest was witnessed, site of arrest, return of spontaneous circulation (ROSC), survival to hospital admission, comorbid illnesses, and survival to hospital discharge were noted. A univariate odds ratio (OR) was first computed to describe the association between the type of airway and survival to hospital discharge. A multivariable logistic regression analysis was performed, adjusting for rhythm, bystander CPR, and whether the arrest was witnessed.

RESULTS

A cohort of 1,294 arrests was evaluated. A total of 1,027 (79.4%) received ETI, while 131 (10.1%) had BVM, 131 (10.1%) had either a Combitube or an esophageal obturator airway, and five (0.4%) had incomplete prehospital records. Fifty-five of 1,294 (4.3%) survived to hospital discharge; there were no survivors in the Combitube/esophageal obturator airway cohort. Even after multivariable adjustment for age, sex, site of arrest, bystander CPR, witnessed arrest, and rhythm on paramedic arrival, the OR for survival to hospital discharge for BVM versus ETI was 4.5 (95% confidence interval [CI] = 2.3-8.9; p<0.0001).

CONCLUSIONS

In this cohort, when compared to BVM ventilation, advanced airway methods were associated with decreased survival to hospital discharge among adult nontraumatic OOHCA patients.