Advanced vs. Basic Life Support in the Treatment of Out-of-Hospital Cardiopulmonary Arrest in the Resuscitation Outcomes Consortium

Resuscitation of out-of-hospital cardiac arrest victims in Austria's largest helicopter emergency medical service: A retrospective cohort study

Background

Helicopter emergency medical services (HEMS) play a fundamental role in prehospital care. However, the impact of HEMS on survival of patients with out-of-hospital cardiac arrest (OHCA) is widely unknown. Therefore, the purpose of this study was to assess demographics, treatment, and outcome of patients with OHCA attended by physician-staffed helicopters.

Methods

Retrospective cohort study enrolling OHCA patients treated by HEMS during a ten-year period (2010-2019) in Austria. Patients were identified using electronic mission records of 13 HEMS bases run by the Austrian Automobile, Motorcycle and Touring Club (OEAMTC), and subsequently matched with the national register of deaths to determine 30-day and one-year survival rates. Results are reported according to the 2015 Utstein Style. Multivariable logistic regression analysis was used to identify factors associated with patient outcome.

Results

In total, 9344 presumed OHCA missions were identified. Cardiopulmonary resuscitation was attempted or continued by HEMS in 3889 cases. Approximately 32.2% of patients achieved return of spontaneous circulation (ROSC) and 22.5% sustained ROSC until arrival at the emergency department. Thirty-day and one-year survival rates were 14.0% and 12.4% respectively. HEMS response time, on-scene time, age, pathogenesis, arrest location, witness-status, first monitored rhythm, bystander automated external defibrillator (AED) use, airway type and administration of adrenaline were independent predictors of 30-day survival.

Conclusions

This study provides an extensive insight into the management of OHCA in an almost nationwide HEMS sample. Thirty-day and one-year survival rates are high, indicating high-quality care and systematic selection of patients with favorable prognosis.

Early intramuscular adrenaline administration is associated with improved survival from out-of-hospital cardiac arrest

BACKGROUND

Early administration of adrenaline is associated with improved survival after out-of-hospital cardiac arrest (OHCA). Delays in vascular access may impact the timely delivery of adrenaline. Novel methods for administering adrenaline before vascular access may enhance survival. The objective of this study was to determine whether an initial intramuscular (IM) adrenaline dose followed by standard IV/IO adrenaline is associated with improved survival after OHCA.

METHODS STUDY DESIGN

We conducted a before-and-after study of the implementation of an early, first-dose IM adrenaline EMS protocol for adult OHCAs. The pre-intervention period took place between January 2010 and October 2019. The post-intervention period was between November 2019 and May 2024.

SETTING

Single-center urban, two-tiered EMS agency.

PARTICIPANTS

Adult, nontraumatic OHCA meeting criteria for adrenaline use.

INTERVENTION

Single dose (5 mg) IM adrenaline. All other care, including subsequent IV or IO adrenaline, followed international guidelines.

MAIN OUTCOMES AND MEASURES

The primary outcome was survival to hospital discharge. Secondary outcomes were time from EMS arrival to the first dose of adrenaline, survival to hospital admission, and favorable neurologic function at discharge.

RESULTS

Among 1405 OHCAs, 420 (29.9%) received IM adrenaline and 985 (70.1%) received usual care. Fifty-two patients received the first dose of adrenaline through the IV or IO route within the post-intervention period and were included in the standard care group analysis. Age was younger and bystander CPR was higher in the IM adrenaline group. All other characteristics were similar between IM and standard care cohorts. Time to adrenaline administration was faster for the IM cohort [(median 4.3 min (IQR 3.0-6.0) vs. 7.8 min (IQR 5.8-10.4)]. Compared with standard care, IM adrenaline was associated with improved survival to hospital admission (37.1% vs. 31.6%; aOR 1.37, 95% CI 1.06-1.77), hospital survival (11.0% vs 7.0%; aOR 1.73, 95% CI 1.10-2.71) and favorable neurologic status at hospital discharge (9.8% vs 6.2%; aOR 1.72, 95% CI 1.07-2.76).

CONCLUSION

In this single-center before-and-after implementation study, an initial IM dose of adrenaline as an adjunct to standard care was associated with improved survival to hospital admission, survival to hospital discharge, and functional survival. A randomized controlled trial is needed to fully assess the potential benefit of IM adrenaline delivery in OHCA.

2024 RECOVER Guidelines: Advanced Life Support. Evidence and knowledge gap analysis with treatment recommendations for small animal CPR

OBJECTIVE

To systematically review the evidence and devise clinical recommendations on advanced life support (ALS) in dogs and cats and to identify critical knowledge gaps.

DESIGN

Standardized, systematic evaluation of literature pertinent to ALS following Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Prioritized questions were each reviewed by Evidence Evaluators, and findings were reconciled by ALS Domain Chairs and Reassessment Campaign on Veterinary Resuscitation (RECOVER) Co-Chairs to arrive at treatment recommendations commensurate to quality of evidence, risk:benefit relationship, and clinical feasibility. This process was implemented using an Evidence Profile Worksheet for each question that included an introduction, consensus on science, treatment recommendations, justification for these recommendations, and important knowledge gaps. A draft of these worksheets was distributed to veterinary professionals for comment for 4 weeks prior to finalization.

SETTING

Transdisciplinary, international collaboration in university, specialty, and emergency practice.

RESULTS

Seventeen questions pertaining to vascular access, vasopressors in shockable and nonshockable rhythms, anticholinergics, defibrillation, antiarrhythmics, and adjunct drug therapy as well as open-chest CPR were reviewed. Of the 33 treatment recommendations formulated, 6 recommendations addressed the management of patients with nonshockable arrest rhythms, 10 addressed shockable rhythms, and 6 provided guidance on open-chest CPR. We recommend against high-dose epinephrine even after prolonged CPR and suggest that atropine, when indicated, is used only once. In animals with a shockable rhythm in which initial defibrillation was unsuccessful, we recommend doubling the defibrillator dose once and suggest vasopressin (or epinephrine if vasopressin is not available), esmolol, lidocaine in dogs, and/or amiodarone in cats.

CONCLUSIONS

These updated RECOVER ALS guidelines clarify the approach to refractory shockable rhythms and prolonged CPR. Very low quality of evidence due to absence of clinical data in dogs and cats continues to compromise the certainty with which recommendations can be made.

Efficiency of two-member crews in delivering prehospital advanced life support cardiopulmonary resuscitation: A scoping review

Background

Advanced Life Support (ALS) during cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA) is frequently administered by two-member crews. However, ALS CPR is mostly designed for larger crews, and the feasibility and efficacy of implementing ALS guidelines for only two rescuers remain unclear.

Objective

This scoping review aims to examine the existing evidence and identify knowledge gaps in the efficiency of pre-hospital ALS CPR performed by two-member teams.

Design

A comprehensive search was undertaken across the following databases: PubMed, Web of Science, SCOPUS, Cochrane Library Trials, and ClinicalTrials.gov. The search covered publications in English or German from January 1, 2005, to November 30, 2023. The review included studies that focused on ALS CPR procedures carried out by two-member teams in adult patients in either simulated or clinical settings.

Results

A total of 22 articles were included in the qualitative synthesis. Seven topics in two-person prehospital ALS/CPR delivery were identified: 1) effect of team configuration on clinical outcome and CPR quality, 2) early airway management and ventilation techniques, 3) mechanical chest compressions, 4) prefilled syringes, 5) additional equipment, 6) adaptation of recommended ALS/CPR protocols, and 7) human factors.

Conclusion

There is a lack of comprehensive data regarding the adaptation of the recommended ALS algorithm in CPR for two-member crews. Although simulation studies indicate potential benefits arising from the employment of mechanical chest compression devices, prefilled syringes, and automation-assisted protocols, the current evidence is too limited to support specific modifications to existing guidelines.

Effect of crew ratio of advanced life support-trained personnel on patients with out-of-hospital cardiac arrest: A systematic review and meta-analysis

BACKGROUND/PURPOSE

This review aimed to investigate the effect of crew ratios of on-scene advanced life support (ALS)-trained personnel on patients with out-of-hospital cardiac arrest (OHCA).

METHODS

We systematically searched PubMed, Ovid EMBASE, and the Cochrane Central Register of Controlled Trials databases from the inception date until September 30, 2022, for eligible studies. Two reviewers independently screened the studies for relevance, extracted data, and quality. We compared the effect of the ratio of on-scene ALS-trained personnel >50 % to those with a ratio ≤50 % among prehospital personnel on the clinical outcomes of OHCA patients. The primary outcome was survival-to-discharge and secondary outcomes were any return of spontaneous circulation (ROSC), sustained ROSC (≥2 h), and favourable neurological outcome at discharge (cerebral performance category scores: 1 or 2). Pooled odds ratios (ORs) were calculated, and the certainty of evidence was assessed.

RESULTS

From 10,864 references, we identified four non-randomised studies, including 16,475 patients. Two studies were performed in Japan and two in Taiwan. There were significant differences in survival-to-discharge (OR: 1.24, 95 % confidence interval [CI]: 1.07-1.44, I2: 7 %), any ROSC (OR:1.22, 95 % CI: 1.04-1.43, I2: 74 %) and sustained ROSC (OR: 1.39, 95 % CI: 1.16-1.65, I2: 40 %), but insignificant differences in favourable neurological outcome at discharge. The overall certainty of evidence was rated as very low for all outcomes.

CONCLUSION

Prehospital ALS care with a ratio of on-scene ALS-trained personnel >50 % could improve OHCA patient outcomes than crew ratios ≤50 %. Further studies are required to reach a robust conclusion.

Optimal duration and timing of basic-life-support-only intervention for patients with out-of-hospital cardiac arrest

To elucidate the relationship between the interval from cardiopulmonary resuscitation initiation to return of spontaneous circulation (ROSC) and neurologically favourable 1-month survival in order to determine the appropriate duration of basic life support (BLS) without advanced interventions. This population-based cohort study included patients aged ≥ 18 years with 9132 out-of-hospital cardiac arrest of presumed cardiac origin who were bystander-witnessed and had achieved ROSC between 2018 and 2020. Patients were classified into two groups based on the resuscitation methods as the "BLS-only" and the "BLS with administered epinephrine (BLS-AE)" groups. Receiver operating characteristic (ROC) curve analysis indicated that administering BLS for 9 min yielded the best neurologically outcome for patients with a shockable rhythm [sensitivity, 0.42; specificity, 0.27; area under the ROC curve (AUC), 0.60] in the BLS-only group. Contrastingly, for patients with a non-shockable rhythm, performing BLS for 6 min yielded the best neurologically outcome (sensitivity, 0.65; specificity, 0.43; AUC, 0.63). After propensity score matching, multivariate analysis revealed that BLS-only resuscitation [6.44 (5.34-7.77)] was associated with neurologically favourable 1-month survival. This retrospective study revealed that BLS-only intervention had a significant impact in the initial minutes following CPR initiation. Nevertheless, its effectiveness markedly declined thereafter. The optimal duration for effective BLS-only intervention varied depending on the patient's initial rhythm. Consequently, advanced interventions should be administered within the first few minutes to counteract the diminishing effectiveness of BLS-only intervention.

Improving EMS response times for out-of-hospital cardiac arrest in urban areas using drone-like vertical take-off and landing air ambulances: An international, simulation-based cohort study

BACKGROUND

Advances in vertical take-off and landing (VTOL) technologies may enable drone-like crewed air ambulances to rapidly respond to out-of-hospital cardiac arrest (OHCA) in urban areas. We estimated the impact of incorporating VTOL air ambulances on OHCA response intervals in two large urban centres in France and Canada.

METHODS

We included adult OHCAs occurring between Jan. 2017-Dec. 2018 within Greater Paris in France and Metro Vancouver in Canada. Both regions utilize tiered OHCA response with basic (BLS)- and advanced life support (ALS)-capable units. We simulated incorporating 1-2 ALS-capable VTOL air ambulances dedicated to OHCA response in each study region, and computed time intervals from call reception by emergency medical services (EMS) to arrival of the: (1) first ALS unit ("call-to-ALS arrival interval"); and (2) first EMS unit ("call-to-first EMS arrival interval").

RESULTS

There were 6,217 OHCAs included during the study period (3,760 in Greater Paris and 2,457 in Metro Vancouver). Historical median call-to-ALS arrival intervals were 21 min [IQR 16-29] in Greater Paris and 12 min [IQR 9-17] in Metro Vancouver, while median call-to-first EMS arrival intervals were 11 min [IQR 8-14] and 7 min [IQR 5-8] respectively. Incorporating 1-2 VTOL air ambulances improved median call-to-ALS arrival intervals to 7-9 min and call-to-first EMS arrival intervals to 6-8 min in both study regions (all P < 0.001).

CONCLUSION

VTOL air ambulances dedicated to OHCA response may improve EMS response intervals, with substantial improvements in ALS response metrics.

Balancing power: Ambulance personnel's lived experience of older persons' participation in care in the presence of municipal care personnel

BACKGROUND

Patient participation is considered to promote well-being and is, therefore, central in care contexts. Care-dependent older persons living at home constitute a vulnerable population with increased ambulance care needs. Care transfers risk challenging participation in care, a challenge that can be accentuated in situations involving acute illness.

AIM

To illuminate meanings of older persons' participation in ambulance care in the presence of municipal care personnel from the perspective of ambulance personnel.

METHOD

A phenomenological hermeneutical method was used to analyse transcripts of narrative interviews with 11 ambulance personnel.

RESULTS

The ambulance personnel's lived experience of older persons' participation includes passive and active dimensions and involves a balancing act between an exercise of power that impedes participation and equalisation of power that empowers participation. The main theme 'Balancing dignity in relation to manipulating the body' included the themes Providing a safe haven and Complying with bodily expressions, which means shouldering responsibility for existential well-being and being guided by reactions. The main theme 'Balancing influence in relation to perceived health risks' included the themes Agreeing on a common perspective, Directing decision-making mandate, and Sharing responsibility for well-being, which means shouldering responsibility for health focusing on risks. Influence is conditional and includes performance requirements for both the older person and municipal care personnel.

CONCLUSION

Care-dependent older persons' participation in care from the perspective of ambulance personnel means recognising passive and active dimensions involving human dignity, the ability to influence care, and optimising care efforts through collaboration. This study provides a deepened understanding of the balancing of power involved in ambulance care determining participation, where power is equalised or exercised depending on personal engagement, health risks, and available care options. The knowledge provided holds the potential to improve ambulance care to benefit older persons in critical life situations.

Delayed arrival of advanced life support adversely affects the neurological outcome in a multi-tier emergency response system

AIM

Prehospital management of out-of-hospital cardiac arrest (OHCA) is based on basic life support, with the addition of advanced life support (ALS) if possible. This study aimed to investigate the effect of delayed arrival of ALS on neurological outcomes of patients with OHCA at hospital discharge.

METHODS

This was a retrospective study of a registry of patients with OHCA. A multi-tier emergency response system was established in the study area. ALS was initiated when the second-arrival team arrived at the scene. A restricted cubic spline curve was used to investigate the relationship between the response time interval of the second-arrival team and neurological outcomes at hospital discharge. Multivariable logistic regression analysis was performed to assess the independent association between the response time interval of the second-arrival team and neurological outcomes of patients at hospital discharge.

RESULTS

A total of 3186 adult OHCA patients who received ALS at the scene were included in the final analysis. A restricted cubic spline curve showed that a long response time interval of the second-arrival team was correlated with a high likelihood of poor neurological outcomes. Meanwhile, multivariable logistic regression analysis showed that a long response time interval of the second-arrival team was independently associated with poor neurological outcomes (odds ratio, 1.10; 95% confidence interval, 1.03-1.17).

CONCLUSION

In a multi-tiered prehospital emergency response system, the delayed arrival of ALS was associated with poor neurological outcomes at hospital discharge.

Impact of Care Interventions on the Survival of Patients with Cardiac Chest Pain

BACKGROUND

Chest pain is considered the second most frequent complaint among patients seeking emergency services. However, there is limited information in the literature about how the care provided to patients with chest pain, when being attended to in the emergency room, influences their clinical outcomes.

AIMS

To assess the relationship between care interventions performed on patients with cardiac chest pain and their immediate and late clinical outcomes and to identify which care interventions were essential to survival.

METHODS

In this retrospective study. We analyzed 153 medical records of patients presenting with chest pain at an emergency service center, São Paulo, Brazil. Participants were divided into two groups: (G1) remained hospitalized for a maximum of 24 h and (G2) remained hospitalized for between 25 h and 30 days.

RESULTS

Most of the participants were male 99 (64.7%), with a mean age of 63.2 years. The interventions central venous catheter, non-invasive blood pressure monitoring, pulse oximetry, and monitoring peripheral perfusion were commonly associated with survival at 24 h and 30 days. Advanced cardiovascular life support and basic support life (p = 0.0145; OR = 8053; 95% CI = 1385-46,833), blood transfusion (p < 0.0077; OR = 34,367; 95% CI = 6489-182,106), central venous catheter (p < 0.0001; OR = 7.69: 95% CI 1853-31,905), and monitoring peripheral perfusion (p < 0.0001; OR = 6835; 95% CI 1349-34,634) were independently associated with survival at 30 days by Cox Regression.

CONCLUSIONS

Even though there have been many technological advances over the past decades, this study demonstrated that immediate and long-term survival depended on interventions received in an emergency room for many patients.

Sudden Cardiac Arrests in the Polish Tatra Mountains: A Retrospective Study

INTRODUCTION

Achieving the optimal survival rate for sudden cardiac arrest in mountains is challenging. The odds of surviving are influenced mainly by distance, response time, and organization of the emergency medical system. The aim of this study was to analyze the epidemiology and outcomes of patients with out-of-hospital cardiac arrest in whom cardiopulmonary resuscitation was performed in the Polish Tatra Mountains.

METHODS

This was a retrospective analysis of data on sudden cardiac arrest collected from the database of the Tatra Mountain Rescue Service and local emergency medical system from 2001 to 2021.

RESULTS

A total of 74 cases of sudden cardiac arrest were recorded. The mortality rate was 88% (65/74). Return of spontaneous circulation was achieved in 22 (30%) patients. A group of survivors was characterized by more frequent use of an automated external defibrillator (AED) (56% vs 14%, P=0.011), a shorter interval between cardiac arrest and emergency team arrival (12 vs 20 min, P=0.005), and a shorter time to initiation of advanced life support (ALS) (12 vs 22 min, P=0.004). All survivors had a shockable initial rhythm. The majority of survivors (8/9, 89%) had a good or moderate neurological outcome.

CONCLUSIONS

This study confirms poor survival rate after sudden cardiac arrest in the mountain area. The use of AED, shockable initial rhythm, and shorter time interval to emergency team arrival and ALS initiation are associated with better outcomes.

Inequities in ambulance allocation associated with transfer delay and mortality in acute coronary syndrome patients: evidence from 89 emergency medical stations in China

BACKGROUND

Allocation of healthcare resources has a great influence on treatment and outcome of patients. This study aimed to access the inequality of ambulance allocation across regions, and estimate the associations between ambulance density and pre-hospital transfer time and mortality of acute coronary syndromes (ACS) patients.

METHODS

This cross-sectional study was based on an integrated database of electronic medical system for 3588 ACS patients from 31 hospitals, ambulance information of 89 emergency medical stations, and public geographical information of 8 districts in Shenzhen, China. The primary outcomes were the associations between ambulance allocation and transfer delay and in-hospital mortality of ACS patients. The Theil index and Gini coefficient were used to assess the fairness and inequality degree of ambulance allocation. Logistic regression was used to model the associations.

RESULTS

There was a significant inequality in ambulance allocation in Shenzhen (Theil index: 0.59), and the inequality of inter-districts (Theil index: 0.38) was greater than that of intra-districts (Theil index: 0.21). The gap degree of transfer delay, ambulance allocation, and mortality across districts resulted in a Gini coefficient of 0.35, 0.53, 0.65, respectively. Ambulance density was negatively associated with pre-hospital transfer time (OR = 0.79, 95%CI: 0.64,0.97, P = 0.026), with in-hospital mortality (OR = 0.31, 95%CI:0.14,0.70, P = 0.005). The ORs of Theil index in transfer time and in-hospital mortality were 1.09 (95%CI:1.01,1.10, P < 0.001) and 1.80 (95%CI:1.15,3.15, P = 0.009), respectively.

CONCLUSIONS

Regional inequities existed in ambulance allocation and has a significant impact on pre-hospital transfer delay and in-hospital mortality of ACS patients. It was suggested to increase the ambulance accessibility and conduct health education for public.

Disparities in Survival Outcomes of Out-of-Hospital Cardiac Arrest Patients between Urban and Rural Areas and the Identification of Modifiable Factors in an Area of South Korea

This retrospective study aimed to compare the survival outcomes of adult out-of-hospital cardiac arrest (OHCA) patients between urban (Busan, Ulsan, Changwon) and rural (Gyeongnam) areas in South Korea and identify modifiable factors in the chain of survival. The primary and secondary outcomes were survival to discharge and modifiable factors in the chain of survival were identified using logistic regression analysis. In total, 1954 patients were analyzed. The survival to discharge rates in the whole region and in urban and rural areas were 6.9%, 8.7% (Busan 8.7%, Ulsan 10.3%, Changwon 7.2%), and 3.4%, respectively. In the urban group, modifiable factors associated with survival to discharge were no advanced airway management (adjusted odds ratio (aOR) 2.065, 95% confidence interval (CI): 1.138–3.747), no mechanical chest compression (aOR 3.932, 95% CI: 2.015–7.674), and an emergency medical service (EMS) transport time of more than 8 min (aOR 3.521, 95% CI: 2.075–5.975). In the rural group, modifiable factors included an EMS scene time of more than 15 min (aOR 0.076, 95% CI: 0.006–0.883) and an EMS transport time of more than 8 min (aOR 4.741, 95% CI: 1.035–21.706). To improve survival outcomes, dedicated resources and attention to EMS practices and transport time in urban areas and EMS scene and transport times in rural areas are needed.

Effects of a designated ambulance team response on prehospital return of spontaneous circulation and advanced cardiac life support of out-of-hospital cardiac arrest: A nationwide natural experimental study

OBJECTIVES

This study aimed to investigate the effects of adding advanced cardiac life support (ACLS) training to an existing basic life support program and the operation of a designated team response for patients with out-of-hospital cardiac arrest (OHCA) on prehospital return of spontaneous circulation (ROSC) and ACLS management.

METHODS

A natural experimental study was conducted for emergency medical service (EMS)-treated adult patients with OHCA in 2020. In 2019, a quarter of the EMS clinicians were trained in a 3-day ACLS courses, and they were designated to be dispatched first in suspected OHCA. Some were dispatched only to major emergencies, such as OHCA and myocardial infarction (dedicated team), while others were dispatched to all emergencies with priority to major ones (non-dedicated team). The exposure was the ambulance response type: dedicated, no-dedicated, and basic teams (others). The primary outcome was prehospital ROSC. The secondary outcomes were prehospital ACLS (advanced airway management and intravenous access). A multivariable logistic regression analysis was conducted to investigate the effect of ambulance response type on study outcomes.

RESULTS

Among 23,512 eligible patients with OHCA, 54.8% (12,874) were treated by the basic team, 36.5% (8,580) by the non-dedicated ACLS team, and 8.8% (2,058) were treated by the dedicated ACLS team. Prehospital ROSC was greater for the designated team than for the basic team (dedicated ACLS team 13.8%, non-dedicated ACLS team 11.3%, and basic team 6.7%) (p <0.01). In the final logistic regression analysis, compared with the basic team, the designated ACLS team was associated with a higher probability of prehospital ROSC (AOR (95% CIs), 1.88 (1.68-2.09) compared to the non-dedicated ACLS team, and 2.46 (2.09-2.90) compared to the dedicated ACLS team), prehospital advanced airway management (1.72 (1.57-1.87) and 1.73 (1.48-2.03), respectively), and intravenous access (2.29 (2.16-2.43) and 2.76 (2.50-3.04), respectively).

CONCLUSION

Additional ACLS training and operation of a designated OHCA team response were associated with higher rates of prehospital ROSC and prehospital ACLS provision. However, further research is needed to find the optimal operation for EMS to improve survival outcomes.

Influence of advanced life support response time on out-of-hospital cardiac arrest patient outcomes in Taipei

Background

The association between out-of-hospital cardiac arrest patient survival and advanced life support response time remained controversial. We aimed to test the hypothesis that for adult, non-traumatic, out-of-hospital cardiac arrest patients, a shorter advanced life support response time is associated with a better chance of survival. We analyzed Utstein-based registry data on adult, non-traumatic, out-of-hospital cardiac arrest patients in Taipei from 2011 to 2015.

Methods

Patients without complete data, witnessed by emergency medical technicians, or with response times of ≥ 15 minutes, were excluded. We used logistic regression with an exposure of advanced life support response time. Primary and secondary outcomes were survival to hospital discharge and favorable neurological outcomes (cerebral performance category ≤ 2), respectively. Subgroup analyses were based on presenting rhythms of out-of-hospital cardiac arrest, bystander cardiopulmonary resuscitation, and witness status.

Results

A total of 4,278 cases were included in the final analysis. The median advanced life support response time was 9 minutes. For every minute delayed in advanced life support response time, the chance of survival to hospital discharge would reduce by 7% and chance of favorable neurological outcome by 9%. Subgroup analysis showed that a longer advanced life support response time was negatively associated with the chance of survival to hospital discharge among out-of-hospital cardiac arrest patients with shockable rhythm and pulse electrical activity groups.

Conclusions

In non-traumatic, adult, out-of-hospital cardiac arrest patients in Taipei, a longer advanced life support response time was associated with declining odds of survival to hospital discharge and favorable neurologic outcomes, especially in patients presenting with shockable rhythm and pulse electrical activity.

Are Pediatric Manual Resuscitators Only Fit For Pediatric Use? A Comparison of Ventilation Volumes in a Moving Ambulance

BACKGROUND

The manual resuscitator device is the most common method of ventilating patients with respiratory failure, either with a facemask, or with an advanced airway such as an ETT. Barotrauma and gastric inflation from excessive ventilation volumes or pressure are concerning complications. Ventilating adult patients with pediatric manual resuscitator may provide more lung-protective tidal volumes based on stationary patient simulations. However, use of a pediatric manual resuscitator in mobile simulations contradictorily generates inadequate tidal volumes.

METHODS

Sixty-two EMS clinicians in a moving ambulance ventilated a manikin using pediatric and adult manual resuscitators in conjunction with oral-pharyngeal airway, i-gel, King LTS-D, or an endotracheal tube.

RESULTS

Oral-pharyngeal airway data were discarded due to EMS clinician inability to produce measurable tidal volumes. Mean ventilation volumes using the pediatric manual resuscitator were inadequate compared to those with the adult manual resuscitator on all other airway devices. In addition, i-gel, King LTS-D, and endotracheal tube volumes were statistically comparable. Paramedics ventilated larger volumes than emergency medical technicians.

CONCLUSIONS

Using a pediatric manual resuscitator on adult patients is not supported by our findings.

Impact of different medical direction policies on prehospital advanced airway management for out-of hospital cardiac arrest patients: A retrospective cohort study

Background

Although optimal prehospital airway management after out-of-hospital cardiac arrest (OHCA) remains undetermined, no studies have compared different advanced airway management (AAM) policies adopted by two hospitals in charge of online medical direction by emergency physicians. We examined the impact of two different AAM policies on OHCA patient survival.

Methods

This observational cohort study included adult OHCA patients treated in Okayama City from 2013 to 2016. Patients were divided into two groups: the O group - those treated on odd days when a hospital with a policy favoring laryngeal tube ventilation (LT) supervised, and the E group - those treated on even days when the other hospital with a policy favoring endotracheal intubation (ETI) supervised. Multiple logistic regression analysis was performed to assess airway device effects. The primary outcome measure was seven-day survival.

Results

Of 2,406 eligible patients, 50.1% were in the O group and 49.9% were in the E group. O group patients received less ETI (1.0% vs. 12.0%) and more LT (53.3% vs. 43.0%) compared with E group patients. In univariate analysis, no differences were observed in seven-day survival (9.4% vs 10.1%). Multiple regression analysis revealed neither LT nor ETI had a significant independent effect on seven-day survival, considering bag-valve mask ventilation as a reference (OR, 0.78; 95% CI, 0.54 to 1.13, OR, 0.79; 95% CI, 0.36 to 1.72, respectively).

Conclusion

Despite different advanced airway medical direction policies in a single city, there were no substantial impact on outcomes for OHCA patients.

Out-of-Hospital Cardiac Arrests Terminated without full Resuscitation Attempts: Characteristics and Regional Variability

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) investigations may elect to exclude cases with resuscitation terminated for reasons other than a full resuscitative attempt. We sought to examine characteristics of these cases and regional variability in classification.

METHODS

Using the North American Resuscitation Outcomes Consortium Epistry, we included adult emergency medical services (EMS)-treated cases, examining the rationale ("futility", do-not resuscitate (DNR) order, "verbal directive", or "obvious death") and timing of resuscitation termination, and the timing of ROSC among hospital-discharge survivors. We tested regional variability in EMS patient arrival-to-termination intervals with one-way ANOVA.

RESULTS

Of 63,554 included cases, 27,232 were declared dead in the prehospital setting: (1) 23,009 (36%) for futility (after a median of 24 minutes (IQR 19-31) of professional resuscitation); (2) 1622 (2.6%) for a DNR order (at 6.3 minutes [IQR 3.0-11]); (3) 1018 (1.6%) for a verbal directive (at 12 minutes [IQR 7.0-17]); and, (4) 1583 (2.5%) for obvious death (at 5.4 minutes [IQR 3.0-9.0]). The EMS patient arrival-to-ROSC interval among hospital-discharge survivors was 7.7 (3.8 - 13) minutes. Among regions, 0.20-12% and 0.20-5.3% were terminated to due to obvious death or verbal directives, respectively. There were significant regional differences in the EMS patient arrival-to-termination interval for futility (p<0.010) and obvious death (p<0.010).

CONCLUSION

There is significant variation in the rationale and interval until termination of resuscitation between regions. Cases terminated due to obvious death or DNR orders/verbal directives often are treated with similar durations of resuscitation as survivors. These data highlight a considerable risk of bias in between-region comparisons or observational analyses.

The factor influencing the rate of ROSC for nontraumatic OHCA in New Taipei city

ABSTRACT

Return of spontaneous circulation (ROSC) from out-of-hospital cardiac arrest (OHCA) is critical for the Emergency Medical Services System. When compared to other developed countries, Taiwan has lower rate of ROSC in OHCA patients.We conducted a retrospective study of cardiac arrest using The Emergency Medical Service Dispatching Center in Northern Taiwan and The Prehospital Care System of New Taipei City Paramedic Service. Patients suffering from nontraumatic OHCA between August of 2019 to February of 2020 were included. We analyzed the cardiopulmonary resuscitation (CPR) quality parameters such as chest compression interruptions, bystander CPR, shockable rhythm, CPR interruption, chest compression fraction (CCF) average, patient transportation in buildings, and adrenaline injection during CPR. Multivariable logistic regression analysis was performed to assess the relationship between potential independent variables and ROSC.In our study, we involved 1265 subjects suffering from nontraumatic OHCA, among which 587 patients met inclusion criteria. We identified that CCF> 0.8, chest compression interruption greater than 3 times, and patient transportation in the building were the most critical factors influencing ROSC. However, patient transportation in a building was identified as a dependent predictor variable (P = .4752).We concluded that CCF > 0.8 and chest compression interruption greater than 3 times were essential factors affecting the CPR ROSC rate. The most significant reason for suboptimal CCF and CPR interruption is patient transportation in a building. Improving the latter point could facilitate high-quality CPR.

Outcomes of Out-of-hospital Cardiac Arrests After a Decade of System-wide Initiatives Optimising Community Chain of Survival in Taipei City

OBJECTIVE

A strengthened chain of survival benefits patient outcomes after out-of-hospital cardiac arrest (OHCA).² Over the past decade, the Taipei Fire Department (TFD) has continuously implemented system-wide initiatives on this issue.We hypothesised that for adult, non-trauma OHCA patients, the bundle of these system-wide initiatives are associated with better outcomes.

METHODS

We conducted a registry-based, retrospective study to examine the association between consecutive system-level initiatives and OHCA survival on a two-yearly basis using trend analysis and multivariable logistic regression. The primary outcome was survival to hospital discharge (STHD) and favourable neurological status.

RESULTS

We analysed 18,076 cases from 2008 to 2017. The numbers of two-yearly cases of OHCA with resuscitation attempts from 2008 to 2017 were 3,576, 3,456, 3,822, 3,811, and 3,411. There was a significant trend of improved STHD (Two-fold) and favourable neurological outcome (Six-fold) over the past decade. Similar trends were observed in the shockable and non-shockable groups. Considering the first 2 years as baseline, the odds of STHD and favourable neurological status in the end of the initiatives increased significantly after adjusting for universally recognised predictors for OHCA survival.

CONCLUSION

For non-trauma adult OHCA in Taipei, continuous, multifaceted system-wide initiatives on the community chain of survival were associated with improved odds of STHD and favourable neurologic outcomes.

Urban-Rural differences in Cardiac Arrest outcomes: a retrospective population-based cohort study

Background

Approximately 10% of people who suffer an out-of-hospital cardiac arrest (OHCA) treated by paramedics survive to hospital discharge. Survival differs by up to 19.2% between urban centres and rural areas. Our goal was to investigate the differences in OHCA survival between urban centres and rural areas.

Methods

This was a retrospective cohort study of OHCA patients treated by Nova Scotia Emergency Medical Services (EMS) in 2017. Cases of traumatic, expected, and noncardiac OHCA were excluded. Data were collected from the Emergency Health Service electronic patient care record system and the discharge abstract database. Geographic information system analysis classified cases as being in urban centres (population > 1000 people) or rural areas, using 2016 Canadian Census boundaries. The primary outcome was survival to hospital discharge. Multivariable logistic regression covariates were age, sex, bystander resuscitation, whether the arrest was witnessed, public location, and preceding symptoms.

Results

A total of 510 OHCAs treated by Nova Scotia Emergency Medical Services were included for analysis. A total of 12% (n = 62) survived to discharge. Patients with OHCAs in urban centres were 107% more likely to survive than those with OHCAs in rural areas (adjusted odds ratio = 2.1; 95% confidence interval = 1.1 to 3.8; P = 0.028). OHCAs in urban centres had a significantly shorter mean time to defibrillation of shockable rhythm (11.2 minutes ± 6.2) vs those in rural areas (17.5 minutes ± 17.3).

Conclusions

Nova Scotia has an urban vs rural disparity in OHCA care that is also seen in densely populated OHCA centres. Survival is improved in urban centres. Further improvements in overall survival, especially in rural areas, may arise from community engagement in OHCA recognition and optimized healthcare delivery.

Hypertonic versus isotonic crystalloid infusion for cerebral perfusion pressure in a porcine experimental cardiac arrest model

BACKGROUND

The effect of intravenous (IV) fluid administration type on cerebral perfusion pressure (CePP) during cardiopulmonary resuscitation (CPR) is controversial. The purpose of this study was to evaluate the association between IV fluid type and CePP in a porcine cardiac arrest model.

METHODS

We randomly assigned 12 pigs to the hypertonic crystalloid, isotonic crystalloid and no-fluid groups. After 4 min of untreated ventricular fibrillation (VF), chest compression was conducted for 2 cycles (CC only). Chest compression with IV fluid infusion (CC + IV) was followed for 2 cycles. Advanced life support, including defibrillation and epinephrine, was added for 8 cycles (ALS phase). Mean arterial pressure (MAP), intracranial pressure (ICP) and CePP were measured. A paired t-test was used to measure the mean difference in CePP.

RESULTS

Twelve pigs underwent the experiment. The hypertonic crystalloid group showed higher CePP values than those demonstrated by the isotonic crystalloid group from ALS cycles 2 to 8. The MAP values in the hypertonic group were higher than those in the isotonic group starting at ALS cycle 2. The ICP values in the hypertonic group were lower than those in the isotonic group starting at ALS cycle 4. From ALS cycles 2 to 8, the reduction in the mean difference in the isotonic group was larger than that in the other groups.

CONCLUSION

In a VF cardiac arrest porcine study, the hypertonic crystalloid group showed higher CePP values by maintaining higher MAP values and lower ICP values than those of the isotonic crystalloid group.

Characteristics Associated With Out-of-Hospital Cardiac Arrests and Resuscitations During the Novel Coronavirus Disease 2019 Pandemic in New York City

Question

What characteristics are associated with out-of-hospital cardiac arrests and death during the COVID-19 pandemic in New York City?

Findings

In this population-based cross-sectional study of 5325 patients with out-of-hospital cardiac arrests, the number undergoing resuscitation was 3-fold higher during the 2020 COVID-19 period compared with during the comparison period in 2019. Patients with out-of-hospital cardiac arrest during 2020 were older, less likely to be white, and more likely to have specific comorbidities and substantial reductions in return and sustained return of spontaneous circulation.

Meaning

Identifying patients at risk for out-of-hospital cardiac arrest and death during the COVID-19 pandemic should lead to interventions in the outpatient setting to help reduce out-of-hospital deaths.

Importance

Risk factors for out-of-hospital death due to novel coronavirus disease 2019 (COVID-19) are poorly defined. From March 1 to April 25, 2020, New York City, New York (NYC), reported 17 118 COVID-19–related deaths. On April 6, 2020, out-of-hospital cardiac arrests peaked at 305 cases, nearly a 10-fold increase from the prior year.

Objective

To describe the characteristics (race/ethnicity, comorbidities, and emergency medical services [EMS] response) associated with outpatient cardiac arrests and death during the COVID-19 pandemic in NYC.

Design, Setting, and Participants

This population-based, cross-sectional study compared patients with out-of-hospital cardiac arrest receiving resuscitation by the NYC 911 EMS system from March 1 to April 25, 2020, compared with March 1 to April 25, 2019. The NYC 911 EMS system serves more than 8.4 million people.

Exposures

The COVID-19 pandemic.

Main Outcomes and Measures

Characteristics associated with out-of-hospital arrests and the outcomes of out-of-hospital cardiac arrests.

Results

A total of 5325 patients were included in the main analysis (2935 men [56.2%]; mean [SD] age, 71 [18] years), 3989 in the COVID-19 period and 1336 in the comparison period. The incidence of nontraumatic out-of-hospital cardiac arrests in those who underwent EMS resuscitation in 2020 was 3 times the incidence in 2019 (47.5/100 000 vs 15.9/100 000). Patients with out-of-hospital cardiac arrest during 2020 were older (mean [SD] age, 72 [18] vs 68 [19] years), less likely to be white (611 of 2992 [20.4%] vs 382 of 1161 [32.9%]), and more likely to have hypertension (2134 of 3989 [53.5%] vs 611 of 1336 [45.7%]), diabetes (1424 of 3989 [35.7%] vs 348 of 1336 [26.0%]), and physical limitations (2259 of 3989 [56.6%] vs 634 of 1336 [47.5%]). Compared with 2019, the odds of asystole increased in the COVID-19 period (odds ratio [OR], 3.50; 95% CI, 2.53-4.84; P < .001), as did the odds of pulseless electrical activity (OR, 1.99; 95% CI, 1.31-3.02; P = .001). Compared with 2019, the COVID-19 period had substantial reductions in return of spontaneous circulation (ROSC) (727 of 3989 patients [18.2%] vs 463 of 1336 patients [34.7%], P < .001) and sustained ROSC (423 of 3989 patients [10.6%] vs 337 of 1336 patients [25.2%], P < .001), with fatality rates exceeding 90%. These associations remained statistically significant after adjustment for potential confounders (OR for ROSC, 0.59 [95% CI, 0.50-0.70; P < .001]; OR for sustained ROSC, 0.53 [95% CI, 0.43-0.64; P < .001]).

Conclusions and Relevance

In this population-based, cross-sectional study, out-of-hospital cardiac arrests and deaths during the COVID-19 pandemic significantly increased compared with the same period the previous year and were associated with older age, nonwhite race/ethnicity, hypertension, diabetes, physical limitations, and nonshockable presenting rhythms. Identifying patients with the greatest risk for out-of-hospital cardiac arrest and death during the COVID-19 pandemic should allow for early, targeted interventions in the outpatient setting that could lead to reductions in out-of-hospital deaths.

European Resuscitation Council Guidelines 2021: Systems saving lives

The European Resuscitation Council (ERC) has produced these Systems Saving Lives guidelines, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include chain of survival, measuring performance of resuscitation, social media and smartphones apps for engaging community, European Restart a Heart Day, World Restart a Heart, KIDS SAVE LIVES campaign, lower-resource setting, European Resuscitation Academy and Global Resuscitation Alliance, early warning scores, rapid response systems, and medical emergency team, cardiac arrest centres and role of dispatcher.

The association between scene time interval and neurologic outcome following adult bystander witnessed out-of-hospital cardiac arrest

OBJECTIVE

To analyze the association between Emergency Medical Services (EMS) scene time interval (STI) and survival with functional neurologic recovery following adult out-of-hospital cardiac arrest (OHCA).

METHODS

A retrospective analysis of prospectively collected data from the national Cardiac Arrest Registry to Enhance Survival from January 2013 to December 2018. All adult non-traumatic, EMS-treated, bystander-witnessed OHCA with complete data were included. Patients with STI times >60 min, defined as the time from EMS arrival at the patient's side to the time the transport vehicle left the scene, unwitnessed OHCA, nursing home events, EMS-witnessed OHCA, or patients with termination of resuscitation in the field were excluded. The primary outcome was survival with functional recovery (Cerebral Performance Category [CPC] = 1 or 2). Multivariable logistic regression was used to quantify the association of STI with the primary.

OUTCOME

RESULTS

67,237 patients met inclusion criteria with 12,098 (18.0%) surviving with functional recovery. Mean STI (SD) for survivors with CPC 1 or 2 was 19 (8.4) and 22.8 (10.5) for those with poor outcomes (death or CPC 3-4; p < 0.001). For every 1-min increase in STI, the adjusted odds of a poor outcome increased by 3.5%; odds ratio = 1.035; 95% CI (1.027, 1.044); p < 0.001. Restricted cubic spline analysis showed increased risk of poor outcome after approximately 20 min.

CONCLUSION

Longer STI times are strongly associated with poor neurologic outcome in bystander-witnessed OHCA patients. After a STI duration of approximately 20 min, the associated risk of a poor neurologic outcome increased more rapidly.

Impact of Pit-Crew Cardiopulmonary Resuscitation on Out-of-Hospital Cardiac Arrest in Saskatoon

BACKGROUND

In the prehospital setting, pit-crew models of cardiopulmonary resuscitation (CPR) have shown improvements in survival after out-of-hospital cardiac arrest (OHCA). Certain districts in North America have adopted this model, including Saskatoon, Saskatchewan, Canada.

OBJECTIVES

Our objectives were to determine whether pit-crew CPR has an impact on survival to discharge after OHCA in Saskatoon, Canada.

METHODS

This was a retrospective pre- and postintervention study. All adult patients who had an OHCA between January 1, 2011 and December 31, 2017 of presumed cardiac origin, in which the resuscitation attempt included CPR by trained prehospital responders, were considered for analysis. Our primary outcome was survival to discharge. Survival to admission and return of spontaneous circulation were secondary outcomes.

RESULTS

There were 860 OHCAs considered for our study. After 46 exclusions there were 442 in the non-pit-crew group (average age 63.7 years; 64.5% male) and 372 in the pit-crew group (average age 63.5 years; 67.5% male). Survival to discharge after an OHCA was 10.4% (95% confidence interval 7.7-13.6%) in the non-pit-crew group and 12.4% (95% CI 9.2-16.2%) in the pit-crew group, which did not meet statistical significance. Return of spontaneous circulation and survival to admission were 48.4% and 31.3%, respectively, in the non-pit-crew group and 46.7% and 32.3%, respectively, in the pit-crew group.

CONCLUSIONS

In our study, implementation of a pit-crew CPR model was not associated with an improvement in survival to discharge after OHCA.

The Association of Death Notification and Related Training with Burnout among Emergency Medical Services Professionals

INTRODUCTION

Death notification is a difficult task commonly encountered during prehospital care and may lead to burnout among EMS professionals. Lack of training could potentiate the relationship between death notification and burnout. The first objective of this study was to describe EMS professionals' experience with death notification and related training. The secondary objective was to assess the associations between death notification delivery, training, and burnout. Methods: We administered an electronic questionnaire to a random sample of nationally-certified EMS professionals. Work-related burnout was measured using the validated Copenhagen Burnout Inventory. Analysis was stratified by certification level to basic life support (BLS) and advanced life support (ALS). The association between the number of adult (≥18 years) patient death notifications delivered in the prior 12 months and burnout was assessed using multivariable logistic regression to adjust for confounding variables. Multivariable logistic regression modeling was used to assess the adjusted association between training and burnout among those who reported delivering at least one death notification in the prior 12 months. Adjusted odds ratios (aOR) and 95% confidence intervals are reported (95% CI). Results: We received 2,333/19,330 (12%) responses and 1,514 were included in the analysis. Most ALS respondents (77%) and one-third of BLS respondents (33%) reported at least one adult death notification in the past year. Approximately half of respondents reported receiving death notification training as part of their initial EMS education program (51% BLS; 52% ALS) and fewer reported receiving continuing education (30% BLS; 44% ALS). Delivering a greater number of death notifications was associated with increased odds of burnout. Among those who delivered at least one death notification, continuing education was associated with reduced odds of burnout. Conclusion: Many EMS professionals reported delivering at least one death notification within the past year. Yet, fewer than half reported training related to death notification during initial EMS education and even fewer reported receiving continuing education. More of those who delivered death notifications experienced burnout, while continuing education was associated with reduced odds of burnout. Future work is needed to develop and evaluate death notification training specifically for EMS professionals.

Plasma Adenylate Levels are Elevated in Cardiopulmonary Arrest Patients and May Predict Mortality

Cerebral and cardiac dysfunction cause morbidity and mortality in postcardiac arrest syndrome (PCAS) patients. Predicting clinical outcome is necessary to provide the optimal level of life support for these patients. In this pilot study, we examined whether plasma ATP and adenylate levels have value in predicting clinical outcome in PCAS patients. In total, 15 patients who experienced cardiac arrest outside the hospital setting and who could be reanimated were enrolled in this study. Healthy volunteers (n = 8) served as controls. Of the 15 PCAS patients, 8 died within 4 days after resuscitation. Of the 7 survivors, 2 lapsed into vegetative states, 1 survived with moderate disabilities, and 4 showed good recoveries. Arterial blood samples were drawn immediately after successful resuscitation and return of spontaneous circulation (ROSC). The concentrations of ATP and other adenylates in plasma were assessed with high-performance liquid chromatography. PCAS patients had significantly higher ATP levels than healthy controls. Plasma ATP levels correlated with lactate levels, Acute Physiology and Chronic Health Evaluation II scores, and the time it took to ROSC (time-to-ROSC). Plasma adenylate levels in patients who died after resuscitation were significantly higher than in survivors. Based on our results and receiver-operating characteristic curve analysis, we conclude that plasma adenylate levels may help predict outcome in PCAS patients.

Effectiveness of the Mobile Emergency Medical Services (SAMU): use of interrupted time series

OBJECTIVE

To evaluate the performance of the Mobile Emergency Medical Services (SAMU) in the ABC Region, using myocardial infarction as tracer condition.

METHODS

The analysis of interrupted time series was the approach chosen to test immediate and gradual effects of the intervention on the study population. The research comprised adjusted monthly time series of the hospital mortality rate by myocardial infarction in the period between 2000 and 2011. Data were extracted from the Mortality Information System (SIM), using segmented regression analysis to evaluate the level and trend of the intervention before and after its implementation. To strengthen the internal validity of the study, a control region was included.

RESULTS

The analysis of interrupted time series showed a reduction of 0.04 deaths per 100,000 inhabitants in the mortality rate compared to the underlying trend since the implementation of the Emergency Medical Services (p = 0.0040; 95%CI: -0.0816 - -0.0162) and a reduction in the level of 2.89 deaths per 100,000 inhabitants (p = 0.0001; 95%CI: -4.3293 - -1.4623), both with statistical significance. Regarding the control region, Baixada Santista, the difference in the result trend between intervention outcome and post-intervention control of -0.0639 deaths per 100,000 inhabitants was statistically significant (p = 0.0031; 95%CI: -0.1060 - -0.0219). We cannot exclude confounders, but we limited their presence in the study by including control region series.

CONCLUSIONS

Although the analysis of interrupted time series has limitations, this modeling can be useful for analyzing the performance of policies and programs. Even though the intervention studied is not a condition that in itself implies effectiveness, the latter would not be present without the former, which, integrated with other conditions, generates a positive result. SAMU is a strategy that must be expanded when formulating and consolidating policies focusing on emergency care.

Learning Impacts of Pretraining Video-Assisted Debriefing With Simulated Errors or Trainees' Errors in Medical Students in Basic Life Support Training: A Randomized Controlled Trial

BACKGROUND

Previous studies demonstrated that pretraining video-assisted debriefing (VAD) with trainees' errors (TE) videotaped in a skills pretest improved skill learning of basic life support (BLS). However, conducting a pretest and preparing TE video examples is resource intensive. Exposing individual trainee's errors to peers might be a threat to learners' psychological safety. We hypothesized pretraining VAD with simulated errors (SE, performed by actors) might have the same beneficial effect on skills learning as pretraining VAD with TE, but avoid drawbacks of TE.

METHODS

Three hundred twenty-two third-year medical students were randomized into 3 groups (the control [C], TE, SE). A videotaped BLS skills pretest was conducted in 3 groups. Then, group C received traditional training with concurrent feedback. Video-assisted debriefing with TE in the pretest or SE was delivered in groups TE or SE, respectively, followed by BLS training without any feedback. Basic life support skills were retested 1 week later (posttest). Students completed a survey to express their preference to TE or SE for VAD in the future.

RESULTS

Higher BLS skills scores were observed in groups TE (85.7 ± 7.0) and SE (86.8 ± 7.5) in the posttest, compared with group C (68.7 ± 13.3, P < 0.001). No skills difference was observed between group TE and SE in the posttest. More trainees (65.8%) preferred SE for VAD.

CONCLUSIONS

Pretraining VAD with SE had an equivalent beneficial effect as VAD with TE on BLS skills learning in medical students. More trainees preferred SE for VAD with regard to psychological safety.

The assessment of the kinematics of the rescuer in continuous chest compression during a 10-min simulation of cardiopulmonary resuscitation

BACKGROUND

In pursuit of improvement in cardiopulmonary resuscitation (CPR), new technologies for the measurement and assessment of CPR quality are implemented. In our study, we assessed the kinematics of the rescuer during continuous chest compression (CCC-CPR). The proper performance of the procedure is a survival predictor for patients with cardiac arrest (CA). The purpose of the study was a prospective assessment of the kinematics of the rescuer's body with consideration given to the depth and rate of chest compression (CC) as the indicator of properly performed CC maneuver by professional and non-professional rescuers during a simulation of a 10-min CCC using a manikin.

METHODS

Forty participants were enrolled in the study. CCC-CPR was performed in accordance with the 2015 AHA guidelines on a manikin positioned on the floor. Kinematic data on the movement were obtained from the measuring system (X-sens MVN Biomech) transmitting information from 17 inertial sensors. Measurement data were imported to the author's program RKO-Kinemat written in the Matlab and C # environments. Two groups of results were distinguished: Group I-results of CC with the depth of ≥ 40 mm and Group 2-CC results with the depth of < 40 mm.

RESULTS

The multiple regression model demonstrated that the path length, left knee flexion angle, and left elbow flexion angle were the essential elements of the rescuer's kinematics that facilitated achieving and maintaining the normal depth of CC.

CONCLUSIONS

We believe that raising the rescuer's hips by moving the center of the rescuer's body over the point of sternal compression increases the value of the CC force vector, thereby increasing the depth of CC. In addition, we observed that, during an effective CC, the rescuer was unable to maintain arms straight and, in consequence, a slight elbow flexion was observed. It, however, did not influence the quality of the maneuver.

Impact of prehospital physician-led cardiopulmonary resuscitation on neurologically intact survival after out-of-hospital cardiac arrest: A nationwide population-based observational study

AIM

The impact of prehospital physician care for out-of-hospital cardiac arrest (OHCA) on long-term neurological outcome is unclear. We aimed to determine the association between emergency medical services (EMS) physician-led cardiopulmonary resuscitation (CPR) versus paramedic-led CPR and neurologically intact survival after OHCA.

METHODS

We assessed 613,251 patients using All-Japan Utstein Registry data from 2011 to 2015 retrospectively. The main outcome measure was 1-month neurologically intact survival after OHCA, defined as Cerebral Performance Category 1 or 2 (CPC 1-2).

RESULTS

Before propensity score matching, the 1-month CPC 1-2 rate was significantly higher in EMS physician-led CPR than in paramedic-led CPR [5.7% (1114/19,551) vs. 2.5% (14,859/593,700), P < 0.001; adjusted odds ratio (aOR), 1.50; 95% confidence interval (CI), 1.40-1.61]. After propensity score matching, EMS physician-led CPR showed more favourable neurological outcomes than paramedic-led CPR [6.0% (996/16,612) vs. 4.6% (766/16,612), P < 0.001; aOR, 1.44; 95% CI, 1.29-1.60]. In most subgroup analyses after matching, physician-led CPR had higher 1-month CPC 1-2 rates than paramedic-led CPR did; however, 1-month CPC 1-2 rates were similar between the two CPR configurations for patients aged <18 years (5.6% vs. 8.2%, P = 0.10; aOR, 0.82; 95% CI, 0.46-1.47) and those who received bystander defibrillation (26.3% vs. 21.5%; P = 0.10; aOR, 1.07; 95% CI, 0.74-1.53).

CONCLUSION

Within the limitations of this retrospective observational research, EMS physician-led CPR for OHCA was associated with improved 1-month neurologically intact survival compared with paramedic-led CPR. However, neurologically intact survival was similar for patients aged <18 years and those receiving bystander defibrillation.