The impact of prehospital transport interval on survival in out-of-hospital cardiac arrest: implications for regionalization of post-resuscitation care

Telephone cardiopulmonary resuscitation, first responder systems, cardiac arrest centers, and global campaigns to save lives

PURPOSE OF REVIEW

The latest resuscitation guidelines contain a new chapter, which focuses on systems improving care for patients with out-of-hospital cardiac arrest (OHCA). In this article, we describe recent developments regarding telephone cardiopulmonary resuscitation (CPR), first responder systems, cardiac arrest centers, and global campaigns.

RECENT FINDINGS

Telephone CPR has been implemented in many countries, and recent developments include artificial intelligence and video calls to improve dispatch assisted CPR. However, the degree of implementation is not yet satisfying. Smartphone alerting systems are effective in reducing the resuscitation-free interval, but many regions do not yet use this technology. Further improvements are needed to reduce response times. Cardiac arrest centers increase the survival chance after OHCA. Specific criteria need to be defined and professional societies should establish a certification process. Global campaigns are effective in reaching people around the world. However, we need to evaluate the effects of the campaigns.

SUMMARY

Telephone CPR, first responder systems, cardiac arrest centers, and global campaigns are highlighted in the recent resuscitation guidelines. However, the degree of implementation is not yet sufficient. We do not only need to implement these measures, but we should also aim to monitor the systems regarding their performance and further improve them.

Association between post-cardiac arrest treatments and clinical outcomes according to scene time interval in out-of-hospital cardiac arrest: Retrospective cross-sectional study

BACKGROUND

Previous studies have reported that Post-Cardiac arrest (PCA) treatments including targeted temperature management (TTM), coronary reperfusion therapy (CRT), and extracorporeal membrane oxygenation (ECMO) are time-sensitive; however, there are no reports of the clinical outcomes of PCA treatment according to the scene time interval (STI). Our study aimed to investigated the clinical outcomes of PCA treatment according to the STI.

METHODS

We used a Korean nationwide OHCA cohort database from January 2017 to December 2020. The inclusion criteria were all adult OHCA patients with a presumed cardiac etiology, bystander-witnessed arrest, and prehospital return of spontaneous circulation (ROSC). The outcomes were survival to discharge and good neurological recovery. The main exposure of interest was PCA treatment. We compared the outcomes using multivariable logistic regression, and interaction terms were included in the final model to assess whether the STI modified the effect of PCA treatment on clinical outcomes of OHCA.

RESULTS

TTM and CRT were associated with high survival to discharge and good neurological recovery. In the interaction analysis, ECMO had an interaction effect with the STI on a good CPC among patients with OHCA [short STI (0 to 11 min) (1.16 (0.77-1.75)), middle STI (12 to 15 min) (0.66 (0.41-1.06)), and long STI (16 to 30 min) (0.59 (0.40-0.88)) (p for interaction <0.05)].

CONCLUSION

In adult bystander-witnessed patients with OHCA with prehospital ROSC, an STI of >16 min was a risk factor for poor neurological outcome in those patients who underwent ECMO.

Prehospital predicting factors using a decision tree model for patients with witnessed out-of-hospital cardiac arrest and an initial shockable rhythm

The effect of prehospital factors on favorable neurological outcomes remains unclear in patients with witnessed out-of-hospital cardiac arrest (OHCA) and a shockable rhythm. We developed a decision tree model for these patients by using prehospital factors. Using a nationwide OHCA registry database between 2005 and 2020, we retrospectively analyzed a cohort of 1,930,273 patients, of whom 86,495 with witnessed OHCA and an initial shockable rhythm were included. The primary endpoint was defined as favorable neurological survival (cerebral performance category score of 1 or 2 at 1 month). A decision tree model was developed from randomly selected 77,845 patients (development cohort) and validated in 8650 patients (validation cohort). In the development cohort, the presence of prehospital return of spontaneous circulation was the best predictor of favorable neurological survival, followed by the absence of adrenaline administration and age. The patients were categorized into 9 groups with probabilities of favorable neurological survival ranging from 5.7 to 70.8% (areas under the receiver operating characteristic curve of 0.851 and 0.844 in the development and validation cohorts, respectively). Our model is potentially helpful in stratifying the probability of favorable neurological survival in patients with witnessed OHCA and an initial shockable rhythm.

The association of the post-resuscitation on-scene interval and patient outcomes after out-of-hospital cardiac arrest

BACKGROUND

After resuscitation from out-of-hospital cardiac arrest (OHCA) by Emergency Medical Services (EMS), the amount of time that should be dedicated to pre-transport stabilization is unclear. We examined whether the time spent on-scene after return of spontaneous circulation (ROSC) was associated with patient outcomes.

METHODS

We examined consecutive adult EMS-treated OHCAs from the British Columbia Cardiac Arrest registry (January 1/2019-June 1/2021) that had on-scene ROSC (sustained to scene departure). The primary outcome was favourable neurological outcome (Cerebral Performance Category ≤ 2) at hospital discharge; secondary outcomes were re-arrest during transport and hospital-discharge survival. Using adjusted logistic regression models, we estimated the association between the post-resuscitation on-scene interval (divided into quartiles) and outcomes.

RESULTS

Of 1653 cases, 611 (37%) survived to hospital discharge, and 523 (32%) had favourable neurological outcomes. The median post-resuscitation on-scene interval was 18.8 minutes (IQR:13.0-25.5). Compared to the first post-resuscitation on-scene interval quartile, neither the second (adjusted odds ratio [AOR] 1.19; 95% CI 0.72-1.98), third (AOR 1.10; 95% CI 0.67-1.81), nor fourth (AOR 1.54; 95% CI 0.93-2.56) quartiles were associated with favourable neurological outcomes; however, the fourth quartile was associated with a greater odds of hospital-discharge survival (AOR 1.73; 95% CI 1.05-2.85), and both the third (AOR 0.40; 95% CI 0.22-0.72) and fourth (AOR 0.44;95% CI 0.24-0.81) quartiles were associated with a lower odds of intra-transport re-arrest.

CONCLUSION

Among resuscitated OHCAs, increased post-resuscitation on-scene time was not associated with improved neurological outcomes, but was associated with improved survival to hospital discharge and decreased intra-transport re-arrest.

Cardiac Arrest Center – Zertifizierung stärkt Patientenzufluss durch den Rettungsdienst

Hintergrund

Seit 2015 empfehlen die internationalen Reanimationsleitlinien die Implementierung von spezialisierten Krankenhäusern (sog. Cardiac Arrest Center, CAC) für die Versorgung von Patienten mit außerklinischem Herz-Kreislauf-Stillstand.

Ziel

Ziel der Studie war es, den potenziellen Einfluss der Zertifizierung von Kliniken als CAC auf das Einweisungsverhalten von Notärzten und Rettungsfachpersonal bei prähospital reanimierten Patienten zu untersuchen.

Methoden

Eine webbasierte anonyme Befragung mit 20 Items wurde vom 15.05. bis zum 15.06.2018 in Deutschland durchgeführt. Zielgruppen waren im Rettungsdienst tätige Notärzte sowie Rettungsfachpersonal.

Wesentliche Ergebnisse

Von 437 Teilnehmern wurden die Ergebnisse von 378 Befragten (n = 292 Notärzte, n = 86 Rettungsfachpersonen) in die statistische Analyse eingeschlossen. 75,1 % (n = 284) gaben an, dass die CAC-Zertifizierung von Krankenhäusern bei ihrem künftigen Einweisungsverhalten von Patienten mit präklinischem Herz-Kreislauf-Stillstand eine Rolle spielen würde. 78,3 % (n = 296) erwarteten, dass die CAC-Zertifizierung zu einer Verbesserung der Patientenversorgung führen wird. 78,8 % (n = 298) befürworteten die Einführung der CAC-Zertifizierung. Die Befragten würden eine zusätzliche Transportzeit von 16,3 min (95 %-KI: 15,2–17,3) akzeptierten, um ein CAC zu erreichen.

Fazit

Die Zertifizierung von Kliniken als CAC hat das Potenzial, die Entscheidung des Rettungsdienstpersonals bei der Zuweisung von Patienten mit einem präklinischen Herz-Kreislauf-Stillstand zu beeinflussen. Aufgrund der limitierten zusätzlich akzeptablen Transportzeit zur Erreichung eines CAC bedarf es eines bundesweiten, engen Netzes zertifizierter Kliniken.

Association of transport time interval with neurologic outcome in out-of-hospital cardiac arrest patients without return of spontaneous circulation on scene and the interaction effect according to prehospital airway management

Objective

This study analyzed the association of transport time interval (TTI) with survival rate and neurologic outcome in out-of-hospital cardiac arrest (OHCA) patients without return of spontaneous circulation (ROSC) and the interaction effect of TTI according to prehospital airway management.

Methods

A retrospective observational study based on the nationwide OHCA database from January 2013 to December 2017 was designed. Emergency medical service (EMS)-treated OHCA patients aged ≥18 years were included. TTI was categorized into four groups of quartiles (≤4, 5–7, 8–11, ≥12 minutes). The primary outcome was favorable neurologic outcome at discharge. The secondary outcome was survival to discharge from the hospital. Multivariable logistic regression was used to analyze outcomes according to TTI. A different effect of TTI according to the administration of prehospital EMS advanced airway was evaluated.

Results

In total, 83,470 patients were analyzed. Good neurologic recovery decreased as TTI increased (1.0% for TTI ≤4 minutes, 0.9% for TTI 5–7 minutes, 0.6% for TTI 8–11 minutes, and 0.5% for TTI ≥12 minutes; P for trend <0.05). The adjusted odds ratio of prolonged TTI (≥12 minutes) was 0.73 (95% confidence interval, 0.57–0.93; P<0.01) for good neurologic recovery. However, the negative effect of prolonged TTI on neurological outcome was insignificant when advanced airway or entotracheal intubation were performed by EMS providers (adjusted odds ratio, 1.17; 95% confidence interval, 0.42–3.29; P=0.76).

Conclusion

EMS TTI was negatively associated with the neurologic outcome of OHCA without ROSC on scene. When advanced airway was performed on scene, TTI was insignificantly associated with the outcome.

Direct Transport to Cardiac Arrest Center and Survival Outcomes after Out-of-Hospital Cardiac Arrest by Urbanization Level

Current guidelines for post-resuscitation care recommend regionalized care at a cardiac arrest center (CAC). Our objectives were to evaluate the effect of direct transport to a CAC on survival outcomes of out-of-hospital cardiac arrests (OHCAs), and to assess interaction effects between CAC and urbanization levels. Adult EMS-treated OHCAs with presumed cardiac etiology between 2015 and 2019 were enrolled. The main exposure was the hospital where OHCA patients were transported by EMS (CAC or non-CAC). The outcomes were good neurological recovery and survival to discharge. Multivariable logistic regression analyses were conducted. Interaction analysis between the urbanization level of the location of arrest (metropolitan or urban/rural area) and the exposure variable was performed. Among the 95,931 study population, 23,292 (24.3%) OHCA patients were transported directly to CACs. Patients in the CAC group had significantly higher likelihood of good neurological recovery and survival to discharge than the non-CAC group (both p < 0.01, aORs (95% CIs): 1.75 (1.63–1.89) and 1.70 (1.60–1.80), respectively). There were interaction effects between CAC and the urbanization level for good neurological recovery and survival to discharge. Direct transport to CAC was associated with significantly better clinical outcomes compared to non-CAC, and the findings were strengthened in OHCAs occurring in nonmetropolitan areas.

Bypassing out-of-hospital cardiac arrest patients to a regional cardiac center: Impact on hemodynamic parameters and outcomes

INTRODUCTION

Current guidelines recommend systematic care for patients who experience out-of-hospital cardiac arrest (OHCA) and the development of cardiac arrest centers (CACs). However, data regarding prolonged transport time of these often hemodynamically unstable patients are limited.

METHODS

Data from a prospective OHCA registry of a regional CAC collected between 2013 and 2017, when all OHCA patients from the district were required to be transferred directly to the CAC, were analyzed. Patients were divided into two subgroups: CAC, when the CAC was the nearest hospital; and bypass, when OHCA occurred in a region of another local hospital but the subject was transferred directly to the CAC (7 hospitals in the district). Data included transport time, baseline characteristics, hemodynamic and laboratory parameters on admission (systolic blood pressure, lactate, pH, oxygen saturation, body temperature, and initial doses of vasopressors and inotropes), and final outcomes (30-day in-hospital mortality, intensive care unit stay, days on artificial ventilation, and cerebral performance capacity at 1 year).

RESULTS

A total of 258 subjects experienced OHCA in the study period; however, 27 were excluded due to insufficient data and 17 for secondary transfer to CAC. As such, 214 patients were analyzed, 111 in the CAC group and 103 in the bypass group. The median transport time was significantly longer for the bypass group than the CAC group (40.5 min [IQR 28.3-55.0 min] versus 20.0 min [IQR 13.0-34.0], respectively; p˂0.0001). There were no differences in 30-day in-hospital mortality, 1-year neurological outcome, or median length of mechanical ventilation. There were no differences in baseline characteristics, initial hemodynamic parameters on admission, catecholamine dosage(s).

CONCLUSION

Individuals who experienced OHCA and taken to a CAC incurred significantly prolonged transport times; however, hemodynamic parameters and/or outcomes were not affected. These findings shows the safety of bypassing local hospitals for a CAC.

Association between Survival and Time of On-Scene Resuscitation in Refractory Out-of-Hospital Cardiac Arrest: A Cross-Sectional Retrospective Study

It is estimated that over 60% of out-of-hospital cardiac arrest (OHCA) patients with a shockable rhythm are refractory to current treatment, never achieve return of spontaneous circulation, or die before they reach the hospital. Therefore, we aimed to identify whether field resuscitation time is associated with survival rate in refractory OHCA (rOHCA) with a shockable initial rhythm. This cross-sectional retrospective study extracted data of emergency medical service (EMS)-treated patients aged ≥ 15 years with OHCA of suspected cardiac etiology and shockable initial rhythm confirmed by EMS providers from the OHCA registry database of Korea. A multivariable logistic regression analysis was conducted for survival to discharge and good neurological outcomes in the scene time interval groups. The median scene time interval for the non-survival and survival to discharge patients were 16 (interquartile range (IQR) 13-21) minutes and 14 (IQR 12-16) minutes, respectively. In this study, for rOHCA patients with a shockable rhythm, continuing CPR for more than 15 min on the scene was associated with a decreased chance of survival and good neurological outcome. In particular, we found that in the patients whose transport time interval was >10 min, the longer scene time interval was negatively associated with the neurological outcome.

Adult Basic Life Support: International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This 2020 International Consensus on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care Science With Treatment Recommendations on basic life support summarizes evidence evaluations performed for 20 topics that were prioritized by the Basic Life Support Task Force of the International Liaison Committee on Resuscitation. The evidence reviews include 16 systematic reviews, 3 scoping reviews, and 1 evidence update. Per agreement within the International Liaison Committee on Resuscitation, new or revised treatment recommendations were only made after a systematic review.

Systematic reviews were performed for the following topics: dispatch diagnosis of cardiac arrest, use of a firm surface for CPR, sequence for starting CPR (compressions-airway-breaths versus airway-breaths-compressions), CPR before calling for help, duration of CPR cycles, hand position during compressions, rhythm check timing, feedback for CPR quality, alternative techniques, public access automated external defibrillator programs, analysis of rhythm during chest compressions, CPR before defibrillation, removal of foreign-body airway obstruction, resuscitation care for suspected opioid-associated emergencies, drowning, and harm from CPR to victims not in cardiac arrest.

The topics that resulted in the most extensive task force discussions included CPR during transport, CPR before calling for help, resuscitation care for suspected opioid-associated emergencies, feedback for CPR quality, and analysis of rhythm during chest compressions. After discussion of the scoping reviews and the evidence update, the task force prioritized several topics for new systematic reviews.

Adult Basic Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This2020 International Consensus on Cardiopulmonary Resuscitation(CPR)and Emergency Cardiovascular Care Science With Treatment Recommendationson basic life support summarizes evidence evaluations performed for 22 topics that were prioritized by the Basic Life Support Task Force of the International Liaison Committee on Resuscitation. The evidence reviews include 16 systematic reviews, 5 scoping reviews, and 1 evidence update. Per agreement within the International Liaison Committee on Resuscitation, new or revised treatment recommendations were only made after a systematic review.

Systematic reviews were performed for the following topics: dispatch diagnosis of cardiac arrest, use of a firm surface for CPR, sequence for starting CPR (compressions-airway-breaths versus airway-breaths-compressions), CPR before calling for help, duration of CPR cycles, hand position during compressions, rhythm check timing, feedback for CPR quality, alternative techniques, public access automated external defibrillator programs, analysis of rhythm during chest compressions, CPR before defibrillation, removal of foreign-body airway obstruction, resuscitation care for suspected opioid-associated emergencies, drowning, and harm from CPR to victims not in cardiac arrest.

The topics that resulted in the most extensive task force discussions included CPR during transport, CPR before calling for help, resuscitation care for suspected opioid-associated emergencies, feedback for CPR quality, and analysis of rhythm during chest compressions. After discussion of the scoping reviews and the evidence update, the task force prioritized several topics for new systematic reviews.

The Association of Extreme Tachycardia and Sustained Return of Spontaneous Circulation after Nontraumatic Out-of-Hospital Cardiac Arrest

Objective

Heart rate (HR), an essential vital sign that reflects hemodynamic stability, is influenced by myocardial oxygen demand, coronary blood flow, and myocardial performance. HR at the time of the return of spontaneous circulation (ROSC) could be influenced by the β1-adrenergic effect of the epinephrine administered during cardiopulmonary resuscitation (CPR), and its effect could be decreased in patients who have the failing heart. We aimed to investigate the association between HR at the time of ROSC and the outcomes of adult out-of-hospital cardiac arrest (OHCA) patients.

Methods

This study was a secondary analysis of a cardiac arrest registry from a single institution from January 2008 to July 2014. The OHCA patients who achieved ROSC at the emergency department (ED) were included, and HR was retrieved from an electrocardiogram or vital sign at the time of ROSC. The patients were categorized into four groups according to the HR (bradycardia (HR < 60), normal HR (60 ≤ HR ≤ 100), tachycardia (100 < HR < 150), and extreme tachycardia (HR ≥ 150)). The primary outcome was the rate of sustained ROSC and the secondary outcomes were the rate of one-month survival and six-month good neurologic outcome.

Results

A total of 330 patients were included. In the univariate logistic regression model, the rate of sustained ROSC increased by 17% as HR increased by every 10 beats per minute (bpm) (odds ratio (OR), 1.171; 95% confidence interval (CI), 1.077–1.274, p < 0.001). In the multivariate logistic regression model, extreme tachycardia was independently associated with a high probability of sustained ROSC compared to normal heart rate (OR, 15.96; 95% CI, 2.04–124.93, p=0.008).

Conclusion

Extreme tachycardia (HR ≥ 150) at the time of ROSC is independently associated with a high probability of sustained ROSC in nontraumatic adult OHCA patients.

Distance travelled to hospital for emergency laparotomy and the effect of travel time on mortality: cohort study

OBJECTIVES

To evaluate whether distance and estimated travel time to hospital for patients undergoing emergency laparotomy is associated with postoperative mortality.

DESIGN

National cohort study using data from the National Emergency Laparotomy Audit.

SETTING

171 National Health Service hospitals in England and Wales.

PARTICIPANTS

22 772 adult patients undergoing emergency surgery on the gastrointestinal tract between 2013 and 2016.

MAIN OUTCOME MEASURES

Mortality from any cause and in any place at 30 and 90 days after surgery.

RESULTS

Median on-road distance between home and hospital was 8.4 km (IQR 4.7-16.7 km) with a median estimated travel time of 16 min. Median time from hospital admission to operating theatre was 12.7 hours. Older patients live on average further from hospital and patients from areas of increased socioeconomic deprivation live on average less far away.We included estimated travel time as a continuous variable in multilevel logistic regression models adjusting for important confounders and found no evidence for an association with 30-day mortality (OR per 10 min of travel time=1.02, 95% CI 0.97 to 1.06, p=0.512) or 90-day mortality (OR 1.02, 95 % CI 0.97 to 1.06, p=0.472).The results were similar when we limited our analysis to the subgroup of 5386 patients undergoing the most urgent surgery. 30-day mortality: OR=1.02 (95% CI 0.95 to 1.10, p=0.574) and 90-day mortality: OR=1.01 (95% CI 0.94 to 1.08, p=0.858).

CONCLUSIONS

In the UK NHS, estimated travel time between home and hospital was not a primary determinant of short-term mortality following emergency gastrointestinal surgery.

Comparing the neurologic outcomes of patients with out-of-hospital cardiac arrest according to prehospital advanced airway management method and transport time interval

OBJECTIVE

The incidences of prehospital advanced airway management by emergency medical technicians in South Korea are increasing; however, whether this procedure improves the survival outcomes of patients experiencing out-of-hospital cardiac arrest remains unclear. The present study aimed to investigate the association between prehospital advanced airway management and neurologic outcomes according to a transport time interval (TTI) using the Korean Cardiac Arrest Research Consortium database.

METHODS

We retrospectively analyzed the favorable database entries that were prospectively collected between October 2015 and December 2016. Patients aged 18 years or older who experienced cardiac arrest that was presumed to be of a medical etiology and that occurred prior to the arrival of emergency medical service personnel were included. The exposure variable was the type of prehospital airway management provided by emergency medical technicians. The primary endpoint was a favorable neurologic outcome.

RESULTS

Of 1,871 patients who experienced out-of-hospital cardiac arrest, 785 (42.0%), 121 (6.5%), and 965 (51.6%) were managed with bag-valve-mask ventilation, endotracheal intubation (ETI), and supraglottic airway (SGA) devices, respectively. SGAs and ETI provided no advantage in terms of favorable neurologic outcome in patients with TTIs ≥12 minutes (odds ratio [OR], 1.37; confidence interval [CI], 0.65-2.87 for SGAs; OR, 1.31; CI, 0.30-5.81 for ETI) or in patients with TTI <12 minutes (OR, 0.57; CI, 0.31-1.07 for SGAs; OR, 0.63; CI, 0.12-3.26 for ETI).

CONCLUSION

Neither the prehospital use of SGA nor administration of ETI was associated with superior neurologic outcomes compared with bag-valve-mask ventilation.

The Effect of Transport Time Interval on Neurological Recovery after Out-of-Hospital Cardiac Arrest in Patients without a Prehospital Return of Spontaneous Circulation

BACKGROUND

Longer transport adversely affects outcomes in out-of-hospital cardiac arrest (OHCA) patients who do not return to spontaneous circulation (ROSC). The aim of this study was to determine the association between the transport time interval (TTI) and neurological outcomes in OHCA patients without ROSC.

METHODS

We analyzed adult OHCA patients with presumed cardiac etiology and without prehospital ROSC from 2012 to 2015. The study population was divided into 2 groups according to STI (short STI [1-5 minutes] and long STI [≥ 6 minutes]). The primary exposure was TTI, which was categorized as short (1-5 minutes), intermediate (6-10 minutes), or long (≥ 11 minutes). The primary outcome was a good neurological recovery at discharge. Multiple logistic regression analysis was used in each STI group.

RESULTS

Among 57,822 patients, 23,043 (40%), 20,985 (36%), and 13,794 (24%) were classified as short, intermediate, and long TTI group. A good neurological recovery occurred in 1.0%, 0.6%, and 0.3% of the patients in the short, intermediate and long TTI group, respectively. Among 12,652 patients with short STI, a good neurological recovery occurred in 2.2%, 1.0%, and 0.4% of the patients in the short, intermediate and long TTI group, respectively. Among 45,570 patients with long STI, a good neurological recovery occurred in 0.7%, 0.5%, and 0.3% of the patients in the short, intermediate and long TTI group, respectively. When short TTI was used as a reference, the adjusted odds ratios (AOR) of TTI for good neurological recovery was different between short STI group and long STI group (AOR [95% confidence interval, 0.46 [0.32-0.67] vs. 0.72 [0.59-0.89], respectively, for intermediate TTI and 0.31 [0.17-0.55] vs. 0.49 [0.37-0.65], respectively, for long TTI).

CONCLUSION

A longer TTI adversely affected the likelihood of a good neurological recovery in OHCA patients without prehospital ROSC. This negative effect was more prominent in short STI group.

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.

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

Background

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

Objectives

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

Data source

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

Participants

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

Main outcome measures

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

Methods

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

Results

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

Limitations

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

Conclusions

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

Future work

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

Funding

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

Variations in Cardiac Arrest Regionalization in California

Introduction

The development of cardiac arrest centers and regionalization of systems of care may improve survival of patients with out-of-hospital cardiac arrest (OHCA). This survey of the local EMS agencies (LEMSA) in California was intended to determine current practices regarding the treatment and routing of OHCA patients and the extent to which EMS systems have regionalized OHCA care across California.

Methods

We surveyed all of the 33 LEMSA in California regarding the treatment and routing of OHCA patients according to the current recommendations for OHCA management.

Results

Two counties, representing 29% of the California population, have formally regionalized cardiac arrest care. Twenty of the remaining LEMSA have specific regionalization protocols to direct all OHCA patients with return of spontaneous circulation to designated percutaneous coronary intervention (PCI)-capable hospitals, representing another 36% of the population. There is large variation in LEMSA ability to influence inhospital care. Only 14 agencies (36%), representing 44% of the population, have access to hospital outcome data, including survival to hospital discharge and cerebral performance category scores.

Conclusion

Regionalized care of OHCA is established in two of 33 California LEMSA, providing access to approximately one-third of California residents. Many other LEMSA direct OHCA patients to PCI-capable hospitals for primary PCI and targeted temperature management, but there is limited regional coordination and system quality improvement. Only one-third of LEMSA have access to hospital data for patient outcomes.

Intravenous Fluid Administration and the Survival of Pre hospital Resuscitated out of Hospital Cardiac Arrest Patients in Thailand

Introduction

Out of Hospital Cardiac Arrest (OHCA) is a leading cause of death worldwide. The Emergency Medical Service (EMS) provides early care to critical OHCA patients. Pre hospital intervention has been improving OHCA survival rate, however it is still unclear for the recommendation of routine infusion of Intravenous (IV) fluids during cardiac arrest resuscitation.

Aim

This study aimed to determine whether IV fluid administration was associated with increasing survival of resuscitated OHCA patients and to assess the survival rate of resuscitated OHCA patients.

Materials and Methods

This cross-sectional analytical study was conducted among 33,006 resuscitated OHCA patients who received emergency medical service in Thailand. Data set from the EMS Registry of the OHCA patients who received Advanced Life Support (ALS) and Cardiopulmonary Resuscitation (CPR) during January 2011 to December 2015 was enrolled as per inclusion criteria. Data were analysed by using both descriptive statistic and multiple logistic regression.

Results

The result indicated that 27,270 OHCA patients (82.62%:95%CI=82.121-83.030%) survived until they reached hospital. In addition, after adjusting for effect modifiers and covariates, it was found that adult (≥18 years) with IV fluid administration were more likely to survive (adjusted OR=4.389; 95% CI: 3.911-4.744) when compared to children (<18 years) with IV fluid administration (adjusted OR =2.952; 95% CI: 2.040-4.273). Other factors associated with OHCA patients' survival were female gender (adjusted OR =1.151; 95% CI: 1.067-1.241), response time per minutes (adjusted OR =0.993; 95% CI: 0.989-0.997), scene time per minutes (adjusted OR=0.948; 95% CI: 0.944-0.952) and transport time per minutes (adjusted OR=0.973, 95%CI: 0.968-0.978).

Conclusion

This study revealed that IV fluid administration was significantly associated with survival of OHCA patients while controlled other covariates including female gender, response time, scene time and transport time. Therefore, it is recommended that the IV fluid administration should be medicated for resuscitated OHCA patients.

The time dependent association of adrenaline administration and survival from out-of-hospital cardiac arrest

BACKGROUND

Recommended for decades, the therapeutic value of adrenaline (epinephrine) in the resuscitation of patients with out-of-hospital cardiac arrest (OHCA) is controversial.

PURPOSE

To investigate the possible time-dependent outcomes associated with adrenaline administration by Emergency Medical Services personnel (EMS).

METHODS

A retrospective analysis of prospectively collected data from a near statewide cardiac resuscitation database between 1 January 2005 and 30 November 2013. Multivariable logistic regression was used to analyze the effect of the time interval between EMS dispatch and the initial dose of adrenaline on survival. The primary endpoints were survival to hospital discharge and favourable neurologic outcome.

RESULTS

Data from 3469 patients with witnessed OHCA were analyzed. Their mean age was 66.3 years and 69% were male. An initially shockable rhythm was present in 41.8% of patients. Based on a multivariable logistic regression model with initial adrenaline administration time interval (AATI) from EMS dispatch as the covariate, survival was greatest when adrenaline was administered very early but decreased rapidly with increasing (AATI); odds ratio 0.94 (95% Confidence Interval (CI) 0.92-0.97). The AATI had no significant effect on good neurological outcome (OR=0.96, 95% CI=0.90-1.02).

CONCLUSIONS

In patients with OHCA, survival to hospital discharge was greater in those treated early with adrenaline by EMS especially in the subset of patients with a shockable rhythm. However survival rapidly decreased with increasing adrenaline administration time intervals (AATI).

The Role of EMS in Regionalized Systems of Care

The parallel advancement of prehospital and in-hospital patient care has provided impetus for the development and implementation of regionalized systems of health care for patients suffering from acute, life-threatening injury and illness. Regardless of the patient's clinical condition, regionalized systems of care revolve around the premise of providing the right care to the right patient at the right time. Current regionalization strategies have shown improvements in the time to patient treatment and in patient outcome, with the incorporation of emergency medical services (EMS) bypass as a key component of the system of care. This article discusses the emerging role of EMS as a critical component of regionalized systems essential to ensure effective and efficient use of resources to improve patient outcome. We also examine some of the benefits and barriers to implementation of regionalized systems of care and avenues for future research.

Postcardiac Arrest Management

Cardiac arrest afflicts more than 300,000 persons annually in North America alone. Advances in systematic, regimented postresuscitation care have lowered mortality and improved neurologic outcomes in select cohorts of patients over the last decade. Postcardiac arrest care now comprises its own link in the chain of survival. For most patients, high-quality postcardiac arrest care begins in the Emergency Department. This article reviews the evidence and offers treatment strategies for the key components of postcardiac arrest care.

Usefulness of cardiac arrest centers - extending lifesaving post-resuscitation therapies: the Arizona experience -

The post-cardiac arrest syndrome is a complex, multisystems response to the global ischemia and reperfusion injury that occurs with the onset of cardiac arrest, its treatment (cardiopulmonary resuscitation) and the re-establishment of spontaneous circulation. Regionalization of post-cardiac arrest care, utilizing specified cardiac arrest centers (CACs), has been proposed as the best solution to providing optimal care for those successfully resuscitated after out-of-hospital cardiac arrest. A multidisciplinary team of intensive care specialists, including critical care/pulmonologists, cardiologists (general, interventional, and electrophysiology), neurologists, and physical medicine/rehabilitation experts, is crucial for such centers. Particular attention to the timely initiation of targeted temperature management and early coronary angiography/percutaneous coronary intervention is best provided by such CACs. A State-wide program of CACs was started in Arizona in 2007. This is a voluntary program, whereby medical centers agree to provide all resuscitated cardiac arrest patients brought to their facility with state-of-the-art post-resuscitation care, including targeted temperature management for comatose patients and strong consideration for emergent coronary angiography for all patients with a likely cardiac etiology for their cardiac arrest. Survival improved by more than 50% at facilities that became CACs with a commitment to provide aggressive post-resuscitation care to all such patients. Providing aggressive, post-resuscitation care is the next real opportunity to increase long-term survival for cardiac arrest patients.

Survival and neurologic outcomes of out-of-hospital cardiac arrest patients who were transferred after return of spontaneous circulation for integrated post-cardiac arrest syndrome care: the another feasibility of the cardiac arrest center

It has been proven that safety and efficiency of out-of-hospital cardiac arrest (OHCA) patients is transported to specialized hospitals that have the capability of performing therapeutic hypothermia (TH). However, the outcome of the patients who have been transferred after return of spontaneous circulation (ROSC) has not been well evaluated. We conducted a retrospective observational study between January 2010 to March 2012. There were primary outcomes as good neurofunctional status at 1 month and the secondary outcomes as the survivals at 1 month between Samsung Medical Center (SMC) group and transferred group. A total of 91 patients were enrolled this study. There was no statistical difference between good neurologic outcomes between both groups (38% transferred group vs. 40.6% SMC group, P=0.908). There was no statistical difference in 1 month survival between the 2 groups (66% transferred group vs. 75.6% SMC group, P=0.318). In the univariate and multivariate models, the ROSC to induction time and the induction time had no association with good neurologic outcomes. The good neurologic outcome and survival at 1 month had no significant differences between the 2 groups. This finding suggests the possibility of integrated post-cardiac arrest care for OHCA patients who are transferred from other hospitals after ROSC in the cardiac arrest center.

Cardiocerebral Resuscitation: An Approach to Improving Survival of Patients With Primary Cardiac Arrest

Out-of-hospital cardiac arrest (OHCA) is a major public health problem. In the United States, OHCA accounts for more premature deaths than any other cause. For over a half-century, the national "Guidelines" for resuscitation have recommended the same initial treatment of primary and secondary cardiac arrests. Using this approach, the overall survival of patients with OHCA, while quite variable, was generally very poor. One reason is that the etiologies of cardiac arrests are not all the same. The vast majority of nontraumatic OHCA in adults are due to a "primary" cardiac arrest, rather than secondary to respiratory arrest. Decades of research and ongoing reviews of the literature led the University of Arizona Sarver Heart Center Resuscitation Research Group to conclude in 2003 that the national guidelines for patients with primary cardiac arrest were not optimal. Therefore, we instituted a new, nonguidelines approach to the therapy of primary cardiac arrest that dramatically improved survival. We called this approach cardiocerebral resuscitation (CCR), as it is the heart and the brain that are the most vulnerable and therefore need to be the focus of resuscitation efforts for these patients. In contrast, cardiopulmonary resuscitation should be reserved for respiratory arrests. Cardiocerebral resuscitation evolved into 3 components: the community, with emphasis for lay individuals to "Check, Call, Compress" and use an automated external defibrillator if available; the Emergency Medical Services, that emphasizes delayed intubation in favor of passive ventilation, urgent and near continuous chest compressions before and immediately after a single indicated shock, and the early administration of epinephrine; and the third component, added in 2007, the designations of hospitals in Arizona that request this designation and agree to receive patients with return of spontaneous circulation following OHCA and to institute state-of-the-art postresuscitation care that includes urgent therapeutic mild hypothermia and cardiac catheterization as a Cardiac Receiving Center. Each component of CCR is critical for optimal survival of patients with primary OHCA. In each city, county, and state where CCR was instituted, the result was a marked increase in survival of the subgroup of patients with OHCA most likely to survive, for example, those with a shockable rhythm. The purpose of this invited article on CCR is to review this alternative approach to resuscitation of patients with primary cardiac arrest and to encourage its adoption worldwide so that more lives can be saved.

Evaluation of the impact of implementing the emergency medical services traumatic brain injury guidelines in Arizona: the Excellence in Prehospital Injury Care (EPIC) study methodology

Traumatic brain injury (TBI) exacts a great toll on society. Fortunately, there is growing evidence that the management of TBI in the early minutes after injury may significantly reduce morbidity and mortality. In response, evidence-based prehospital and in-hospital TBI treatment guidelines have been established by authoritative bodies. However, no large studies have yet evaluated the effectiveness of implementing these guidelines in the prehospital setting. This article describes the background, design, implementation, emergency medical services (EMS) treatment protocols, and statistical analysis of a prospective, controlled (before/after), statewide study designed to evaluate the effect of implementing the EMS TBI guidelines-the Excellence in Prehospital Injury Care (EPIC) study (NIH/NINDS R01NS071049, "EPIC"; and 3R01NS071049-S1, "EPIC4Kids"). The specific aim of the study is to test the hypothesis that statewide implementation of the international adult and pediatric EMS TBI guidelines will significantly reduce mortality and improve nonmortality outcomes in patients with moderate or severe TBI. Furthermore, it will specifically evaluate the effect of guideline implementation on outcomes in the subgroup of patients who are intubated in the field. Over the course of the entire study (~9 years), it is estimated that approximately 25,000 patients will be enrolled.

Association between ambulance distance to hospitals and mortality from acute diseases in Japan: national database analysis

OBJECTIVE

The aim of this study was to evaluate the relationship between ambulance distance to hospitals and mortality from acute diseases using the national database in Japan.

DESIGN

Geospatial ecological study.

SETTING

We collected the data of transport distance to hospitals from the Diagnosis Procedure Combination database and that of mortality per 100 000 from some acute diseases from the database of life tables by the Ministry of Health, Labour and Welfare in Japan.

PARTICIPANTS

A total of 108 314 patients (40 882 patients with acute myocardial infarction, 31 632 patients with brain infarction, 4992 patients with subarachnoid hemorrhage, and 30 808 patients with pneumonia) were referred in Japan in 2008.

MAIN OUTCOME MEASURES

We evaluated the association between the mean transport distance to hospitals and the mortality from acute diseases using simple linear regression analysis. This correlation was evaluated separately for each acute disease.

RESULTS

The mean transport distances to hospitals were 8.1 km for acute myocardial infarction, 8.3 km for brain infarction, 9.5 km for subarachnoid hemorrhage, and 7.6 km for pneumonia, whereas the mortalities per 100,000 were 34.6 for acute myocardial infarction, 60.4 for brain infarction, 11.2 for subarachnoid hemorrhage, and 91.6 for pneumonia. Simple linear regression analysis revealed significant positive correlations between transport distance and mortality per 100,000 for acute myocardial infarction and brain infarction (R2 = 0.315 and 0.398, P < .001, respectively). Otherwise, moderate positive correlations between transport distance and mortality per 100,000 were shown for subarachnoid hemorrhage and pneumonia (R2 = 0.112, P < .012 and .233, P < .001, respectively).

CONCLUSIONS

This study suggests that the ambulance distance to hospitals significantly influences the risk of mortality for some acute diseases in Japan. Further studies are needed to confirm this association.

Global health and emergency care: a resuscitation research agenda--part 2

At the 2013 Academic Emergency Medicine global health consensus conference, a breakout session to develop a research agenda for resuscitation was held. Two articles are the result of that discussion. This second article addresses data collection, management, and analysis and regionalization of postresuscitation care, resuscitation programs, and research examples around the world and proposes a strategy to strengthen resuscitation research globally. There is a need for reliable global statistics on resuscitation, international standardization of data, and development of an electronic standard for reporting data. Regionalization of postresuscitation care is a priority area for future research. Large resuscitation clinical research networks are feasible and can give valuable data for improvement of service and outcomes. Low-cost models of population-based research, and emphasis on interventional and implementation studies that assess the clinical effects of programs and interventions, are needed to determine the most cost-effective strategies to improve outcomes. The global challenge is how to adapt research findings to a developing world situation to have an effect internationally.

The cardiocerebral resuscitation protocol for treatment of out-of-hospital primary cardiac arrest

Out-of-hospital cardiac arrest (OHCA) is a significant public health problem in most westernized industrialized nations. In spite of national and international guidelines for cardiopulmonary resuscitation and emergency cardiac care, the overall survival of patients with OHCA was essentially unchanged for 30 years--from 1978 to 2008 at 7.6%. Perhaps a better indicator of Emergency Medical System (EMS) effectiveness in treating patients with OHCA is to focus on the subgroup that has a reasonable chance of survival, e.g., patients found to be in ventricular fibrillation (VF). But even in this subgroup, the average survival rate was 17.7% in the United States, unchanged between 1980 and 2003, and 21% in Europe, unchanged between 1980 and 2004. Prior to 2003, the survival of patients with OHCA, in VF in Tucson, Arizona was less than 9% in spite of incorporating previous guideline recommendations. An alternative (non-guidelines) approach to the therapy of patients with OHCA and a shockable rhythm, called Cardiocerebral Resuscitation, based on our extensive physiologic laboratory studies, was introduced in Tucson in 2003, in rural Wisconsin in 2004, and in selected EMS areas in the metropolitan Phoenix area in 2005. Survival of patients with OHCA due to VF treated with Cardiocerebral Resuscitation in rural Wisconsin increased to 38% and in 60 EMS systems in Arizona to 39%. In 2004, we began a statewide program to advocate chest compression-only CPR for bystanders of witnessed primary OHCA. Over the next five years, we found that survival of patients with a shockable rhythm was 17.7% in those treated with standard bystander CPR (mouth-to-mouth ventilations plus chest compression) compared to 33.7% for those who received bystander chest-compression-only CPR. This article on Cardiocerebral Resuscitation, by invitation following a presentation at the 2011 Danish Society Emergency Medical Conference, summarizes the results of therapy of patients with primary OHCA treated with Cardiocerebral Resuscitation, with requested emphasis on the EMS protocol.

The hospital's role in improving survival of patients with out-of-hospital cardiac arrest

Out-of-hospital cardiac arrest (OHCA) is a major public health problem. Unfortunately, in spite of recurring updated guidelines, survival of patients with OHCA had been unchanged for decades. Recently, new approaches to patients with OHCA during the community and prehospital phases of therapy for cardiac arrest have resulted in a dramatic improvement in survival. Further improvement in survival has resulted from hospitals designated as Cardiac Receiving Centers. These centers are committed to the treatment of post-cardiac arrest syndrome by providing 24/7 therapeutic mild hypothermia, urgent cardiac catheterization and percutaneous coronary intervention, evidence-based termination of resuscitation protocols that limit premature withdrawal of care, protocol to address organ donation, commitment of cardiocerebral resuscitation training in their community, and a commitment and proven ability of data collection to assure that instituted changes result in improved survival. This newer aspect of hospital practice is an aspect that needs to be embraced by either becoming a Cardiac Receiving Center or partnering with other hospitals that can provide this critically important service.