Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: The utstein style

The Association of Racial Residential Segregation and Survival After Out-of-Hospital Cardiac Arrest in the United States

Background

Residential segregation has been identified as drivers of disparities in health outcomes, but further work is needed to understand this association with clinical outcomes for out-of-hospital cardiac arrest (OHCA). We utilized Cardiac Arrest Registry to Enhance Survival (CARES) dataset to examine if there are differences in survival to discharge and survival with good neurological outcome, as well as likelihood of bystander CPR, using validated measures of racial, ethnic, and economic segregation.

Methods

We conducted a retrospective observational study using data from the Cardiac Arrest Registry to Enhance Survival (CARES) dataset to examine associations among adult OHCA patients. The primary predictor was the Index of Concentration at the Extremes (ICE), a validated measure that includes race, ethnicity, and income across three measures at the census tract level. The primary outcomes were survival to discharge and survival with good neurological status. A multivariable modified Poisson regression modeling approach with random effects at the EMS agency and hospital level was utilized.

Results

We identified 626,264 OHCA patients during the study period. The mean age was 62 years old (SD 17.2 years), and 35.7% (n =223,839) of the patients were female. In multivariable models, we observed an increased likelihood of survival to discharge and survival with good neurological outcome for those patients residing in predominately White population census tracts and higher income census tracts as compared to lower income Black and Hispanic/Latinx population census tracts (RR 1.24, CI 1.20-1.28) and a 32% increased likelihood of receiving bystander CPR in higher income census tracts as compared to reference (RR 1.32, CI 1.30-1.34).

Conclusions

In this study examining the association of measures of residential segregation and OHCA outcomes, there was an increased likelihood of survival to discharge, survival with good neurological status, and likelihood of receiving B-CPR for those patients residing in predominately White population and higher income census tracts when compared to predominately Black and/or Hispanic Latinx populations and lower income census tracts. This research suggests that areas impacted by residential and economic segregation are important targets for both public policy interventions as well as addressing disparities in care across the chain of survival for OHCA.

Description of the 2020 NEMSIS Public-Release Research Dataset

Background: The National Emergency Medical Services Information System (NEMSIS) is a federally funded program designed to standardize Emergency Medical Services (EMS) patient care reporting and facilitate state and national data repositories for the assessment and improvement of EMS systems of care. This manuscript characterizes the 2020 submissions to the National EMS Database, detailing the strengths and limitations associated with use of these data for public health surveillance, improving prehospital patient care, critical resource allocation, clinician safety, system quality assurance and research purposes.Methodology: Using the 2020 NEMSIS Public-Release Research Dataset (NEMSIS dataset), we evaluated the dataset completeness (i.e., presence of missing/null values), dataset content and assessed data generalizability. The analysis focused on 911 EMS activations resulting in the treatment and transport of a patient, except for out-of-hospital cardiac arrests for which all patients were included regardless of transport status.Results: In 2020, 43,488,767 EMS activations were reported to the National EMS Database by 12,319 agencies serving 50 states and territories. Of the 19,533,036 911 EMS activations reportedly treating and transporting a patient, the majority were attended by "non-volunteer" clinicians (77%) working in a fire-based EMS agency (35%) certified to offer Advanced Life Support (ALS) Paramedic service (80%) and located in an urban area (82%). 911 call centers most often dispatched EMS for "sick person" (20%), while EMS clinicians most likely reported asthenia (7%) as the patient's primary symptom as well as the clinician's primary impression (6%), and documented "fall on same level, slip, or trip" as the most common cause of injury (37%). The NEMSIS dataset demonstrates some "missingness" and element inconsistencies, but methods may be employed to mitigate these data limitations.Conclusions: The National EMS Database is a free and publicly available resource for evaluating EMS system utilization, response, and prehospital patient care. Understanding the characteristics of the underlying dataset and known data limitations will help ensure proper analysis and reporting of research and quality metrics based on nationally standardized NEMSIS data.

Extracorporeal Cardiopulmonary Resuscitation and Survival After Refractory Cardiac Arrest: Is ECPR Beneficial?

The level of evidence of expert recommendations for starting extracorporeal cardiopulmonary resuscitation (ECPR) in refractory out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) is low. Therefore, we reported our experience in the field to identify factors associated with hospital mortality. We conducted a retrospective cohort study of all consecutive patients treated with ECPR for refractory cardiac arrest without return to spontaneous circulation, regardless of cause, at the Caen University Hospital. Factors associated with hospital mortality were analyzed. Eighty-six patients (i.e., 35 OHCA and 51 IHCA) were included. The overall hospital mortality rate was 81% (i.e., 91% and 75% in the OHCA and IHCA groups, respectively). Factors independently associated with mortality were: sex, age > 44 years, and time from collapse until extracorporeal life support (ECLS) initiation. Interestingly, no-shockable rhythm was not associated with mortality. The receiver operating characteristic-area under the curve values of pH value (0.75 [0.60-0.90]) and time from collapse until ECLS initiation over 61 minutes (0.87 [0.76-0.98]) or 74 minutes (0.90 [0.80-1.00]) for predicting hospital mortality showed good discrimination performance. No-shockable rhythm should not be considered a formal exclusion criterion for ECPR. Time from collapse until ECPR initiation is the cornerstone of success of an ECPR strategy in refractory cardiac arrest.

Use of backboards in cardiopulmonary resuscitation: a systematic review and meta-analysis

To achieve optimal chest compression depth, victims of cardiac arrest should be placed on a firm surface. Backboards are usually placed between the mattress and the back of a patient in the attempt to increase cardiopulmonary resuscitation (CPR) quality, but their effectiveness remains controversial. A systematic search was performed to include studies on humans and simulation manikins assessing CPR quality with or without backboards. The primary outcome of the meta-analysis was the difference in chest compression depth between these two conditions. Out of 557 records, 16 studies were included in the review and all were performed on manikins. The meta-analysis, performed on 15 articles, showed that the use of backboards during CPR increases chest compression depth by 1.46 mm in manikins. Despite statistically significant, this increase could have a limited clinical impact on CPR, due to the substantial heterogeneity of experimental conditions and the scarcity of other CPR quality indicators.

Cancer is not associated with higher short or long-term mortality after successful resuscitation from out-of-hospital cardiac arrest when adjusting for prognostic factors

Objective:

As the prevalence of malignancies in the general population increases, the odds of an out-of-hospital cardiac arrest (OHCA) patient having a history of cancer likewise increases, and the impact on post-cardiac arrest care and mortality is not well known. We aimed to investigate 30-day and 1-year mortality after successful resuscitation in patients with cancer prior to OHCA compared with OHCA patients without a previous cancer diagnosis.

Methods:

A cohort of 993 consecutive OHCA patients with successful resuscitation during 2007–2011 was included. Vital status was obtained from the Danish Civil Register, and cancer diagnoses from the Danish National Patient Register dating back to 1994. Primary endpoints were 30-day, 1-year and long-term mortality (no cancer: mean 811 days; cancer: mean 406 days), analysed by Cox regression. Functional status assessed by cerebral performance category at discharge and use of post-resuscitation care were secondary endpoints.

Results:

A total of 119 patients (12%) were diagnosed with cancer prior to OHCA. Mortality was higher in patients with cancer (30-day 69% vs. 58%, P=0.01); however, after adjustment for prognostic factors cancer was no longer associated with higher mortality (hazard ratio (HR)30 days 0.98, 95% confidence interval (CI) 0.76–1.27, P=0.88; HR1 year 0.99, 95% CI 0.78–1.27, P=0.96 HRend of follow-up 0.95, 95% CI 0.75–1.20, P=0.67). Favourable cerebral performance category scores in patients alive at discharge did not differ (cerebral performance category 1 or 2 n=310 (84%) vs. n=31 (84%), P=1).

Conclusion:

Cancer prior to OHCA was not associated with higher mortality in patients successfully resuscitated from OHCA when adjusting for confounders. Cancer prior to OHCA should be used with caution when performing prognostication after OHCA.

Age-specific trends in incidence and survival of out-of-hospital cardiac arrest from presumed cardiac cause in Denmark 2002-2014

BACKGROUND

The general cardiovascular health has improved throughout the last few decades for middle-aged and older individuals, but the incidence of several cardiovascular diseases is reported to increase in younger people. We aimed to assess the age-specific incidence and mortality rates associated with out-of-hospital-cardiac-arrest (OHCA) between 2002 and 2014.

METHODS

We used the Danish Cardiac Arrest Register to identify patients with OHCA of presumed cardiac etiology. We calculated the annual incidence rates (IR) and 30-day mortality rates (MR) in 7 age groups (18-34 years, 35-44 years, 45-54 years, 55-64 years, 65-74 years, 75-84 years and ≥85 years, and ≤50 vs. >50 years).

RESULTS

Between 2002 and 2014, IR of OHCA decreased in individuals aged 65-74 and 75-84 years (158.08 to 111.2 and 237.5 to 217.09 per 100,000 person-years) and increased in the oldest from 201.01 to 325.4 pr. 100.000 person-years. In 18-34-years incidence of OHCA increased from 1.7 to 2.6 per 100.000 person-years. When stratifying into age ≤50 vs. >50 years, the IR deviated in those >50 years (from 117.8 in 2002 to 91 in 2008 to 117.4 in 2014100,000 person-years). The prevalence of acute myocardial infarction and heart failure prior to OHCA increased in the younger patient group in contrast to the older segment (AMI: ≤50 years: 10% to 16%, vs. >50 years: 25% to 23%, heart failure: ≤50 years 6% to 14%, vs. >50 years: 21% to 24%).

CONCLUSION

Over the last decades, incidence rates of OHCA decreased in individuals aged 65-84, but increased in individuals older than 85. An increase was also observed in younger individuals, potentially indicating a need for better cardiovascular disease prevention in younger adults.

A Conceptual Framework to Reduce Inpatient Preventable Deaths

BACKGROUND

Efforts to reduce preventable deaths in the in-hospital setting should target both cardiopulmonary arrest (CPA) prevention and optimal resuscitation. This requires consideration of a broad range of clinical issues and processes. A comprehensive, integrated system of care (SOC) that links data collection with a modular education program to reduce preventable deaths has not been defined.

METHODS

This study was conducted in two urban university hospitals from 2005 to 2009. The Advanced Resuscitation Training (ART) program was implemented in 2007, incorporating hands-on resuscitative skills and in-hospital-specific training with an institutional resuscitation database. Linkage between the database and training modules occurs via the ART Matrix, which classifies all CPA events into the following etiologies: sepsis, hemorrhage, pulmonary embolus, heart failure, tachyarrhythmias, bradyarrhythmias, acute respiratory distress syndrome, non-intubated pulmonary disease, obstructive apnea, traumatic brain injury, ischemic brain injury, and intracranial mass lesions. This taxonomy was validated using descriptive statistics, before-and-after analysis evaluating CPA incidence, and multivariate logistic regression to predict CPA survival.

RESULTS

A total of 336 inpatients suffered a cardiopulmonary arrest during the study period-187 in the pre-ART period and 149 in the post-ART period. The vast majority of CPA events were categorized using the ART Matrix with high inter-observer reliability. As anticipated, changes in CPA incidence and survival were observed for some Matrix categories but not others following ART implementation. In addition, multivariate logistic regression revealed strong independent associations between taxonomy classifications and outcome.

CONCLUSION

A novel SOC using a unique taxonomy for arrest classification appears to be effective at reducing inpatient CPA incidence and outcome.

Survival factors of hospitalized out-of-hospital cardiac arrest patients in Taiwan: A retrospective study

The chain of survival has been shown to improve the chances of survival for victims of cardiac arrest. Post-cardiac arrest care has been demonstrated to significantly impact the survival of out-of-hospital cardiac arrest (OHCA). How post-cardiac arrest care influences the survival of OHCA patients has been a main concern in recent years. The objective of this study was to assess the survival outcome of hospitalized OHCA patients and determine the factors associated with improved survival in terms of survival to discharge. We conducted a retrospective observational study by analyzing records from the National Health Insurance Research Database of Taiwan from 2007 to 2013. We collected cases with an International Classification of Disease Clinical Modification, 9^threvision primary diagnosis codes of 427.41 (ventricular fibrillation, VF) or 427.5 (cardiac arrest) and excluded patients less than 18 years old, as well as cases with an unknown outcome or a combination of traumatic comorbidities. We then calculated the proportion of survival to discharge among hospitalized OHCA patients. Factors associated with the dependent variable were examined by logistic regression. Statistical analysis was conducted using SPSS 22 (IBM, Armonk, NY). Of the 11,000 cases, 2,499 patients (22.7%) survived to hospital discharge. The mean age of subjects who survived to hospital discharge and those who did not was 66.7±16.7 and 71.7±15.2 years, respectively. After adjusting for covariates, neurological failure, cardiac comorbidities, hospital level, intensive care unit beds, transfer to another hospital, and length of hospital stay were independent predictors of improved survival. Cardiac rhythm on admission was a strong factor associated with survival to discharge (VF vs. non-VF: adjusted odds ratio: 3.51; 95% confidence interval: 3.06–4.01). In conclusion, cardiac comorbidities, hospital volume, cardiac rhythm on admission, transfer to another hospital and length of hospital stay had a significant positive association with survival to discharge in hospitalized OHCA patients in Taiwan.

Strengthening Links in the “Chain of Survival”: A Singapore Perspective

Introduction

The concept of the chain of survival is widely accepted. The four links viz. early access, early cardiopulmonary resuscitation (CPR), early defibrillation and early Advanced Cardiac Life Support (ACLS) are related to survival after pre-hospital cardiac arrest. Owing to the dismal survival-to-discharge figures locally, we conducted this study to identify any weaknesses in the chain, looking in particular at bystander CPR rates and times to Basic Cardiac Life Support (BCLS) and ACLS.

Methods and materials

A retrospective cohort study was conducted in the Emergency Department of an urban tertiary 1500-bed hospital. Over a 12-month period, all cases of non-trauma out-of-hospital cardiac arrest were evaluated.

Results

A total of 142 cases of non-trauma out-of-hospital cardiac arrest were identified; the majority being Chinese (103/142, 72.5%) and male (71.8%) with a mean age of 64.3±7.8 years (range 23–89 yrs). Most patients (111/142, 78.2%) did not receive any form of life support until arrival of the ambulance crew. Mean time from collapse to arrival of the ambulance crew and initiation of BCLS and defibrillation was 9.2±3.5 minutes. Mean time from collapse to arrival in the Emergency Department (and thus ACLS) was 16.8±7.1 minutes. Three patients (2.11%) survived to discharge.

Conclusion

There is a need to (i) facilitate layperson training in bystander CPR, and (ii) enhance paramedic training to include ACLS, in order to improve the current dismal survival outcomes from out-of-hospital cardiac arrest in Singapore.

Performance review of regional emergency medical service pre-arrival cardiopulmonary resuscitation with or without dispatcher instruction: a population-based observational study

Background

To investigate variations in emergency medical service (EMS) pre‐arrival cardiopulmonary resuscitation (CPR), including both bystander CPR without dispatch assistance and dispatch‐assisted CPR (DACPR).

Methods

We carried out an observational study by implementing EMS pre‐arrival CPR reports in three fire agencies. We included adult, non‐traumatic, and non‐EMS witnessed out‐of‐hospital cardiac arrests. This reporting system comprised the dispatch instruction process and bystander CPR quality based on evaluations by EMS crews who arrived on the scene. Bystander CPR was categorized as “ongoing CPR” if the bystander was performing CPR when the EMS reached the patient's side and “good‐quality CPR” if the CPR was performed proficiently. We compared the frequencies of ongoing and good‐quality CPR in the bystander CPR already started without dispatch assistance (CPR in progress) group and DACPR group.

Results

Of 688 out‐of‐hospital cardiac arrests, CPR was already started in 150 cases (CPR in progress group). Dispatcher CPR instruction was provided in 368 cases. Among these, callers started chest compressions in 162 cases (DACPR group). Ongoing CPR was performed in 220 cases and was more frequent in the DACPR group (128/162 [79.0%] versus 92/150 [61.3%], P < 0.001). Good‐quality CPR was more frequent in the CPR in progress group, but the difference was not statistically significant (36/92 [39.1%] versus 42/128 [29.0%], P = 0.888).

Conclusions

Ongoing CPR and good‐quality CPR were not frequent in EMS pre‐arrival CPR. Detailed analysis of dispatch instructions and bystander CPR can contribute to improvement in EMS pre‐arrival CPR.

Barriers to EMS System Evaluation: Problems Associated with Field Data Collection

For more than two decades, emergency medical services (EMS) systems have proliferated primarily based upon governmental impetus and funding at the federal, state, and local levels. Although many of the foundations of patient care rendered in these systems have been based upon intuitive logic, the understanding of the impact on patient outcome is poor, at best. The reasons for the current status are varied, but five issues are preeminent:

1) The authority for the development of these medical systems has been based primarily in political and bureaucratic institutions which have little or no medical expertise;

2) Little attention has been paid to system evaluation, particularly in the area of cost-effectiveness;

3) Few academic medical institutions have become involved in EMS research;

4) Traditional approaches to medical research primarily are disease-specific and are not multidisciplinary. Thus these are not useful for evaluating and understanding the highly complex and uncontrolled environmental interactions that typify EMS systems; and

5) The process of efficiently and reliably collecting accurate data in the prehospital setting is extremely difficult.

Sex and Age Aspects in Patients Suffering From Out-Of-Hospital Cardiac Arrest: A Retrospective Analysis of 760 Consecutive Patients

Cardiopulmonary resuscitation (CPR) is indicated in patients suffering from out-of-hospital cardiac arrest. Several studies suggest a sex- and age-based bias in the treatment of these patients. This particular bias may have a significant impact on the patient's outcome. However, the reasons for these findings are still unclear and discussed controversially. Therefore, the aim of this study was to retrospectively analyze treatment and out-of-hospital survival rates for potential sex- and age-based differences in patients requiring out-of-hospital CPR provided by an emergency physician in the city of Zurich, Switzerland.A total of 3961 consecutive patients (2003-2009) were included in this retrospective analysis to determine the frequency of out-of-hospital CPR and prehospital survival rate, and to identify potential sex- and age-based differences regarding survival and treatment of the patients.Seven hundred fifty-seven patients required CPR during the study period. Seventeen patients had to be excluded because of incomplete or inconclusive documentation, resulting in 743 patients (511 males, 229 females) undergoing further statistical analysis. Female patients were significantly older, compared with male patients (68 ± 18 [mean ± SD] vs 64 ± 18 years, P = .012). Men were resuscitated slightly more often than women (86.4% vs 82.1%). Overall out-of-hospital mortality rate was found to be 81.2% (492/632 patients) with no differences between sexes (82.1% for males vs 79% for females, odds ratio 1.039, 95% confidence interval 0.961-1.123). No sex differences were detected in out-of-hospital treatment, as assessed by the different medications administered, initial prehospital Glasgow Coma Scale, and prehospital suspected leading diagnosis.The data of our study demonstrate that there was no sex-based bias in treating patients requiring CPR in the prehospital setting in our physician-led emergency ambulance service.

Aminophylline for bradyasystolic cardiac arrest in adults

BACKGROUND

In cardiac ischaemia, the accumulation of adenosine may lead to or exacerbate bradyasystole and diminish the effectiveness of catecholamines administered during resuscitation. Aminophylline is a competitive adenosine antagonist. Case studies suggest that aminophylline may be effective for atropine-resistant bradyasystolic arrest.

OBJECTIVES

To determine the effects of aminophylline in the treatment of patients in bradyasystolic cardiac arrest, primarily survival to hospital discharge. We also considered survival to admission, return of spontaneous circulation, neurological outcomes and adverse events.

SEARCH METHODS

For this updated review, we searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, LILACS, ClinicalTrials.gov and WHO International Clinical Trials Registry Platform in November 2014. We checked the reference lists of retrieved articles, reviewed conference proceedings, contacted experts and searched further using Google.

SELECTION CRITERIA

All randomised controlled trials comparing intravenous aminophylline with administered placebo in adults with non-traumatic, normothermic bradyasystolic cardiac arrest who were treated with standard advanced cardiac life support (ACLS).

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed the studies and extracted the included data. We contacted study authors when needed. Pooled risk ratio (RR) was estimated for each study outcome. Subgroup analysis was predefined according to the timing of aminophylline administration.

MAIN RESULTS

We included five trials in this analysis, all of which were performed in the prehospital setting. The risk of bias was low in four of these studies (n = 1186). The trials accumulated 1254 participants. Aminophylline was found to have no effect on survival to hospital discharge (risk ratio (RR) 0.58, 95% confidence interval (CI) 0.12 to 2.74) or on secondary survival outcome (survival to hospital admission: RR 0.92, 95% CI 0.61 to 1.39; return of spontaneous circulation: RR 1.15, 95% CI 0.89 to 1.49). Survival was rare (6/1254), making data about neurological outcomes and adverse events quite limited. The planned subgroup analysis for early administration of aminophylline included 37 participants. No one in the subgroup survived to hospital discharge.

AUTHORS' CONCLUSIONS

The prehospital administration of aminophylline in bradyasystolic arrest is not associated with improved return of circulation, survival to admission or survival to hospital discharge. The benefits of aminophylline administered early in resuscitative efforts are not known.

Cerebral Oximetry as a Real-Time Monitoring Tool to Assess Quality of In-Hospital Cardiopulmonary Resuscitation and Post Cardiac Arrest Care

Background

Regional cerebral oxygen saturation (rSO₂) as assessed by near infrared frontal cerebral spectroscopy decreases in circulatory arrest and increases with high-quality cardiopulmonary resuscitation. We hypothesized that higher rSO₂ during cardiopulmonary resuscitation and after return of spontaneous circulation (ROSC) would predict survival to discharge and neurological recovery.

Methods and Results

This prospective case series included patients experiencing in-hospital cardiac arrest. Cerebral oximetry was recorded continuously from initiation of resuscitation until ROSC and up to 48 hours post-arrest. Relationships between oximetry data during these time periods and outcomes of resuscitation survival and survival to discharge were analyzed. The cohort included 27 patients. Nineteen (70.3%) achieved ROSC, and 8 (29.6%) survived to discharge. Median arrest duration was 20.8 minutes (range =8 to 74). There was a significant difference in rSO₂ between resuscitation survivors and resuscitation nonsurvivors at initiation of the resuscitative efforts (35% versus 17.5%, P =0.03) and during resuscitation (36% versus 15%, P =0.0008). No significant association was observed between rSO₂ at ROSC or during the post-arrest period and survival to discharge. Among patients who survived to discharge, there was no association between cerebral performance category and rSO₂ at ROSC, during resuscitation, or post-arrest.

Conclusions

Higher rSO₂ levels at initiation of resuscitation and during resuscitation are associated with resuscitation survival and may reflect high-quality cardiopulmonary resuscitation. However, in this small series, rSO₂ was not predictive of good neurological outcome. Larger studies are needed to determine whether this monitoring modality can be used to improve clinical outcomes.

Resuscitation and post resuscitation care of the very old after out-of-hospital cardiac arrest is worthwhile

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is associated with a poor prognosis. As comorbidity and frailty increase with age; ethical dilemmas may arise when OHCA occur in the very old.

OBJECTIVES

We aimed to investigate mortality, neurological outcome and post resuscitation care in octogenarians (≥80) to assess whether resuscitation and post resuscitation care should be avoided.

METHODS

During 2007-2011 consecutive OHCA-patients were attended by the physician-based Emergency Medical Services-system in Copenhagen. Pre-hospital data based on Utstein-criteria, and data on post resuscitation care were collected. Primary outcome was successful resuscitation; secondary endpoints were 30-day mortality and neurological outcome (Cerebral Performance Category (CPC)).

RESULTS

2509 OHCA-patients with attempted resuscitation were recorded, 22% (n=558) were octogenarians/nonagenarians. 166 (30% of all octogenarians with resuscitation attempted) octogenarians were successfully resuscitated compared to 830 (43% with resuscitation attempted) patients <80 years. 30-day mortality in octogenarians was significantly higher after adjustment for prognostic factors (HR=1.61 CI: 1.22-2.13, p<0.001). Octogenarians received fewer coronary angiographies (CAG) (14 vs. 37%, p<0.001), and had lower odds of receiving CAG by multivariate logistic regression (OR: 0.19, CI: 0.08-0.44, p<0.001). A favorable neurological outcome (CPC 1/2) in survivors to discharge was found in 70% (n=26) of octogenarians compared to 86% (n=317, p=0.03) in the younger patients.

CONCLUSION

OHCA in octogenarians was associated with a significantly higher mortality rate after adjustment for prognostic factors. However, the majority of octogenarian survivors were discharged with a favorable neurological outcome. Withholding resuscitation and post resuscitation care in octogenarians does not seem justified.

Prognostic Implications of Level-of-Care at Tertiary Heart Centers Compared With Other Hospitals After Resuscitation From Out-of-Hospital Cardiac Arrest

Background—

Studies have found higher survival rates after out-of-hospital cardiac arrest and admission to tertiary heart centers. The aim was to examine the level-of-care at tertiary centers compared with nontertiary hospitals and the association with outcome after out-of-hospital cardiac arrest.

Methods and Results—

Consecutive out-of-hospital cardiac arrest patients (n=1078) without ST-segment–elevation myocardial infarction admitted to tertiary centers (54%) and nontertiary hospitals (46%) were included (2002–2011). Patient charts were reviewed focusing on level-of-care and comorbidity. Survival to discharge differed significantly with 45% versus 24% of patients discharged alive ( P <0.001), and after adjustment for prognostic factors admissions to tertiary centers were still associated with lower 30-day mortality (hazard ratio, 0.78 [0.64–0.96; P =0.02]), independent of comorbidity. The adjusted odds of predefined markers of level-of-care were higher in tertiary centers: admission to intensive care unit (odds ratio [OR], 1.8 [95% confidence interval, 1.2–2.5]), temporary pacemaker (OR, 6.4 [2.2–19]), vasoactive agents (OR, 1.5 [1.1–2.1]), acute (<24 hours) and late coronary angiography (OR, 10 [5.3–22] and 3.8 [2.5–5.7]), neurophysiological examination (OR, 1.8 [1.3–2.6]), and brain computed tomography (OR, 1.9 [1.4–2.6]), whereas no difference in therapeutic hypothermia was noted. Patients at tertiary centers were more often consulted by a cardiologist (OR, 8.6 [5.0–15]), had an echocardiography (OR, 2.8 [2.1–3.7]), and survivors more often had implantable cardioverter defibrillator’s implanted (OR, 2.1 [1.2–3.6]).

Conclusions—

Admissions to tertiary centers were associated with significantly higher survival after out-of-hospital cardiac arrest in patients without ST-segment–elevation myocardial infarction in the Copenhagen area even after adjustment for prognostic factors including comorbidity. Level-of-care seems higher in tertiary centers both in the early phase, during the intensive care unit admission, and in the workup before discharge. The varying level-of-care may contribute to the survival difference; however, differences in comorbidity do not seem to matter significantly.

Vasopressin Associated With an Increase in Return of Spontaneous Circulation in Acidotic Cardiopulmonary Arrest Patients

Background: During respiratory and metabolic acidosis, the vasoconstrictive effects of epinephrine may be blunted, whereas the response to vasopressin remains unchanged. The impact of this effect during advanced cardiac life support (ACLS) remains unclear. Objective: Determine if vasopressin therapy in combination with epinephrine was associated with improved outcomes in patients with cardiac arrest compared to epinephrine alone. The primary outcome was difference in rate of return of spontaneous circulation (ROSC). Secondary outcomes included evaluation of rates of ROSC for patients with an initial pH <7.2 and by initial pulseless rhythm. Methods: Single-center, retrospective review conducted from July 2010 to July 2012. Patients ≥18 years of age with documented cardiac arrest requiring ACLS and vasopressor therapy were included. Results: A total of 101 patients met inclusion criteria. There was no difference in rate of ROSC (56% vs 60%, P = 0.68) or survival to hospital discharge (9% vs 5%, P = 0.46) between patients who received vasopressin in combination with epinephrine (n = 43) compared to epinephrine alone (n = 58). Subgroup analysis of ROSC in patients with an arterial pH of <7.2 (n = 35) showed an increased rate of ROSC (63% vs 37%, P = 0.01) in the vasopressin plus epinephrine group versus the epinephrine alone group, respectively. Subgroup analysis by initial cardiac rhythm showed no difference in rate of ROSC. Conclusions: Vasopressin in combination with epinephrine demonstrated improved ROSC in cardiac arrest patients with initial arterial pH <7.2 compared with epinephrine alone, without improving survival to hospital discharge.

Implications for public access defibrillation placement by non-traumatic out-of-hospital cardiac arrest occurrence in Singapore

INTRODUCTION

The American Heart Association recommends automated external defibrillator placement in public areas with a high probability (>1) of out-of-hospital cardiac arrest (OHCA) occurring in 5 years. We aimed to determine the incidence rate of OHCA for different location categories in Singapore.

METHODS

Cardiac arrest incidence was obtained from a national registry. Denominators for the actual number of sites per location category were obtained from public accessible sources, government officers and purchased statistics. Analysis was performed and expressed in terms of the corresponding 95% confidence interval (CI).

RESULTS

From 1 October 2001 to 14 October 2004, 2254 non-trauma OHCA cases were included. Mean age for arrests was 62.2 years, with 67.5% men. The location category with the highest incidence of cardiac arrests per site per 5 years was Port/Airport/Immigration Checkpoints (5.24 CI [3.66-7.20]). Top individual site with high average incidence of cardiac arrests per 5 years was Changi Airport (25.0 CI [16.18-36.90]). Seventy-one per cent of arrests occurred in residential areas. The postal sector with the highest average incidence per 100 000 population was Bedok Reservoir (54.89), whereas that with the highest population density was Bukit Merah/Alexandra with 348.14 population per 100 km(2) .

CONCLUSION

In this study, we found the categories and individual sites that clearly fulfilled the American Heart Association criteria of at least 1 OHCA per site per 5 years. This study provides a model of how cardiac arrest registry data can be used to guide local health policy on automated external defibrillator deployment.

Abnormal breathing of sudden cardiac arrest victims described by laypersons and its association with emergency medical service dispatcher-assisted cardiopulmonary resuscitation instruction

Background

Current guidelines for cardiopulmonary resuscitation (CPR) emphasise that emergency medical service (EMS) dispatchers should identify sudden cardiac arrest (CA) with abnormal breathing and assist lay rescuers performing CPR. However, lay rescuers description of abnormal breathing may be inconsistent, and it is unclear how EMS dispatchers provide instruction for CPR based on the breathing status of the CA victims described by laypersons.

Methods and results

To investigate the incidence of abnormal breathing and the association between the EMS dispatcher-assisted CPR instruction and layperson CPR, we retrospectively analysed 283 witnessed CA cases whose information regarding breathing status of CA victims was available from population-based prospective cohort data. In 169 cases (59.7%), laypersons described that the CA victims were breathing in various ways, and that the victims were ‘not breathing’ in 114 cases (40.3%). Victims described as breathing in various ways were provided EMS dispatch-instruction for CPR less frequently than victims described as ‘not breathing’ (27.8% (47/169) vs 84.2% (96/114); p<0.001). Multivariate logistic regression showed that EMS dispatch-instruction for CPR was associated significantly with layperson CPR (adjusted OR, 11.0; 95% CI, 5.72 to 21.2).

Conclusions

This population-based study indicates that 60% of CA victims showed agonal respiration, which was described as breathing in various ways at the time of EMS call. Although EMS dispatch-instruction was associated significantly with an increase in layperson CPR, abnormal breathing was associated with a much lower rate of CPR instruction and, in turn, was related to a much lower rate of bystander CPR.

Out-of-hospital traumatic cardiac arrest: an underrecognized source of organ donors

Whereas the gap between organ supply and demand remains a worldwide concern, resuscitation of out-of-hospital traumatic cardiac arrest (TCA) remains controversial. The aim of this study is to evaluate, in a prehospital medical care system, the number of organs transplanted from victims of out-of-hospital TCA. This is a descriptive study. Victims of TCA are collected in the out-of-hospital cardiac arrest registry of the French North Alpine Emergency Network from 2004 to 2008. In addition to the rates of admission and survival, brain-dead patients and the organ transplanted are described. Among the 540 resuscitated patients with suspected TCA, 79 were admitted to a hospital, 15 were discharged alive from the hospital, and 22 developed brain death. Nine of these became eventually organ donors, with 31 organs transplanted, all functional after 1 year. Out-of-hospital TCA should be resuscitated just as medical CA. With a steady prevalence in our network, 19% of admitted TCA survived to discharge, and 11% became organ donors. It is essential to raise awareness among rescue teams that out-of-hospital TCA are an organ source to consider seriously.

Emergency coronary angiography in comatose cardiac arrest patients: do real-life experiences support the guidelines?

AIMS

To describe the use of emergency coronary angiography (CAG) and primary percutaneous coronary intervention (PCI) and the association with short- and long-term survival in consecutive comatose survivors after out-of-hospital cardiac arrest (OHCA).

METHODS

In the period 2004-10, a total of 479 consecutive patients with OHCA of suspected cardiac cause were referred to a tertiary cardiac centre, 360 patients were comatose and admitted to the ICU for post-resuscitative care. The population was stratified in two groups according to the pattern of the first ECG obtained after re-established circulation; ST-segment elevation (STEMI, n=116) and ECG without STEMI pattern (No-STEMI, n=244). Emergency CAG (≤12 hours after OHCA) was performed at the discretion of the attending cardiologist. Primary outcome was 30-day and 1-year survival.

RESULTS

Emergency CAG was performed in all patients in the STEMI group compared to 82 (34%) in the group without STEMI pattern (p<0.0001) with significant coronary lesions found in 108 (93%) compared to 43 (52%) patients, respectively (p<0.0001). Survival at 30 day according to emergency CAG vs. no emergency CAG was 65% in the STEMI group compared to 66% and 54% in the group without STEMI pattern (p log-rank=0.11). The use of emergency CAG in the group without STEMI pattern was not associated with reduced mortality (HRadjusted=0.69, 95% CI 0.4-1.2, p=0.18).

CONCLUSIONS

In comatose survivors of OHCA presenting with STEMI, a high prevalence of coronary disease and culprit lesions suitable for emergency PCI was found, whereas in patients without STEMI pattern, significant coronary stenosis was less frequent. Clinical benefits of emergency CAG/PCI in comatose survivors of OHCA presenting without STEMI could not be identified.

Aminophylline for bradyasystolic cardiac arrest in adults

BACKGROUND

In cardiac ischaemia, the accumulation of adenosine may lead to or exacerbate bradyasystole and diminish the effectiveness of catecholamines administered during resuscitation. Aminophylline is a competitive adenosine antagonist. Case studies suggest that aminophylline may be effective for atropine-resistant bradyasystolic arrest.

OBJECTIVES

To determine the effects of aminophylline in the treatment of patients in bradyasystolic cardiac arrest, primarily survival to hospital discharge. We also considered survival to admission, return of spontaneous circulation, neurological outcomes and adverse events.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library, Issue 4, 2009), MEDLINE, EMBASE, CINAHL, LILACS, ClinicalTrials.gov and WHO International Clinical Trials Registry Platform. We checked the reference lists of retrieved articles, reviewed conference proceedings, contacted experts and searched further using Google. The search strategy was updated in March 2012.

SELECTION CRITERIA

All randomised controlled trials comparing intravenous aminophylline with administered placebo in adults with non-traumatic, normothermic bradyasystolic cardiac arrest who were treated with standard advanced cardiac life support (ACLS).

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed the studies and extracted the included data. We contacted study authors when needed. Pooled risk ratio (RR) was estimated for each study outcome. Subgroup analysis was predefined according to the timing of aminophylline administration.

MAIN RESULTS

Five trials are included in this analysis, all of which were performed in the prehospital setting. The risk of bias was low in four of these studies (n = 1186). The trials accumulated 1254 participants. Aminophylline was found to have no effect on survival to hospital discharge (RR 0.58, 95% confidence interval (CI) 0.12 to 2.74) or on secondary survival outcome (survival to hospital admission: RR 0.92, 95% CI 0.61 to 1.39; return of spontaneous circulation: RR 1.15, 95% CI 0.89 to 1.49). Survival was rare (6/1254), making data about neurological outcomes and adverse events quite limited. The planned subgroup analysis for early administration of aminophylline included 37 participants. No one in the subgroup survived to hospital discharge.

AUTHORS' CONCLUSIONS

The prehospital administration of aminophylline in bradyasystolic arrest is not associated with improved return of circulation, survival to admission or survival to hospital discharge. The benefits of aminophylline administered early in resuscitative efforts are not known.

Low rate of secondary prevention ICDs in the general population: multiple-year multiple-source surveillance of sudden cardiac death in the Oregon Sudden Unexpected Death Study

INTRODUCTION

Sudden cardiac death (SCD) is a large public health problem that warrants on-going evaluation in the general population. While single-year community-based studies have been performed there is a lack of studies that have extended evaluation to multiple years in the same community.

METHODS AND RESULTS

From the on-going Oregon Sudden Unexpected Death Study, we analyzed prospectively identified SCD cases in Multnomah County, Ore, (population ≈700,000) from February 1, 2002 to January 31, 2005. Detailed information ascertained from multiple sources (first responders, clinical records, and medical examiner) was analyzed. A total of 1,175 SCD cases were identified (61% male) with a mean age of 65 ± 18 years for men versus 70 ± 20 for women (P < 0.001). The overall incidence rate for the period was 58/100,000 residents/year. One-quarter (24.6%) was ≤ 55 years of age. The most common initial rhythm was ventricular tachycardia or fibrillation (39% of cases, survival 27%) followed by asystole (36%, survival 0.7%) and pulseless electrical activity (23%, survival 6%). Among subjects that underwent resuscitation, the rate of survival to hospital discharge was 12% and overall survival to hospital discharge irrespective of resuscitation was 8%. Of the 68 survivors, 16 (24%) received a secondary prevention ICD.

CONCLUSION

We report annualized SCD incidence from a multiple-year, multiple-source community-based study, with higher than expected rates of women and subjects age ≤ 55 years. The low implantation rate of secondary prevention ICDs is likely to be multifactorial, but there are potential implications for recalibration of the projected need for ICD implantation; larger and more detailed studies are warranted.

Automatic External Defibrillation and Its Effects on Neurologic Outcome in Cardiac Arrest Patients in an Urban, Two-Tiered EMS System

Objective:

To describe the use of the Automatic External Defibrillation (AED) device in an urban, two-tiered Emergency Medical Service (EMS) response setting with regard to its potential effects on cardiac arrest patient survival and neurologic outcome.

Methods:

A retrospective and descriptive design was utilized to study all cardiac arrest patients that had resuscitations attempted in the prehospital environment over a 30-month period. The study took place in a two-tiered EMS system serving an urban population of 368,383 persons. The first tier of EMS response is provided by the City Fire Department, which is equipped with a standard AED device. All first-tier personnel are trained to the level of Emergency Medical Technician-Basic. The second tier of EMS response is provided by personnel from one of two ambulance services. All second-tier personnel are trained to the level of Emergency Medical Technician-Paramedic.

Results:

271 cardiac arrest patients were identified for inclusion. One-hundred nine of these patients (40.2%) had an initial rhythm of either ventricular fibrillation or pulseless ventricular tachycardia and were shocked using the AED upon the arrival of first-tier personnel. Forty-two patients (38.5%) in this group had a return of spontaneous circulation in the field and 22 (20.2%) survived to hospital discharge. Of the survivors, 17 (77.3%) had moderate to good neurologic function at discharge base on the Glasgow-Pittsburgh Cerebral Performance Categories. Faster response times by the first-tier personnel appeared to correlate with better neurologic outcomes.

Conclusion:

First responder-based AED usage on patients in ventricular fibrillation or pulseless ventricular tachycardia can be applied successfully in an urban setting utilizing a two-tiered EMS response. In this study, a 20.2% survival to hospital discharge rate was obtained. Seventy-seven percent of these survivors had a moderate to good neurologic outcome based on the Glasgow-Pittsburgh Cerebral Performance Categories.

Emergency response time after out-of-hospital cardiac arrest

OBJECTIVES

To investigate the emergency response time after out-of-hospital cardiac arrest (OHCA) in four cities in Serbia.

METHODS

A prospective, two-year, multicenter study was designed. Using the Utstein template we recorded out-of-hospital CPR (OHCPR) and analyzed the time sequence segment of the variables in OHCA and CPR gold standards. Multivariable logistic regression models were developed using emergency response time as the primary independent variable and survival to return of spontaneous circulation (ROSC), survival to hospital discharge (HD), and one-year survival (1y) as the dependent variable. ROC curves represent cut off time dependent survival data.

RESULTS

During the study period, the median time of recognition OHCA was 5.5 min, call receipt was 1 min and the call-response interval was 7 min. The median time required to verify OHCA and ALS onset was 10 min. ALS was carried on for 30.5 min (SD=21.3). Abandonment of further CPR/death occurred after 29 min. The first defibrillation shock was performed after 13.3±9.0 min, endotracheal tube was placed after 16.8±9.4 min and the first adrenaline dose was injected after 18.9±9.3 min. Higher survival (ROSC, HD, 1y) rate was found when CPR is performed within the first 4 min after OHCA.

CONCLUSION

The emergency response time within 4 min was associated with improved survival to ROSC, HD and 1y after OHCA. Despite the fact that our results are in accordance with the findings published in other papers, there is still a need to take all appropriate measures in order to decrease the emergency response time after OHCA.

Cognitive and functional outcome after out of hospital cardiac arrest

The nature of residual cognitive deficits after out of hospital cardiac arrest (OHCA) is incompletely described and has never been defined against a cardiac control (CC) group. The objective of this study is to examine neuropsychological outcomes 3 months after OHCA in patients in a "middle range" of acute severity. Thirty prospective OHCA admissions with coma >1 day and responsive but confused at 1 week, and 30 non-OHCA coronary care admissions were administered standard tests in five cognitive domains. OHCA subjects fell into two deficit profiles. One group (N = 20) had mild memory deficits and borderline psychomotor deficits compared to the CC group; 40% had returned to work. The other group (N = 10) had severe impairments in all domains. Coma duration was associated with group. Neither group had a high prevalence of depression. For most patients within the "middle range" of acute severity of OHCA, cognitive and functional outcomes at 3 months were encouraging.

Standard cardiopulmonary resuscitation versus active compression-decompression cardiopulmonary resuscitation with augmentation of negative intrathoracic pressure for out-of-hospital cardiac arrest: a randomised trial

BACKGROUND

Active compression-decompression cardiopulmonary resuscitation (CPR) with decreased intrathoracic pressure in the decompression phase can lead to improved haemodynamics compared with standard CPR. We aimed to assess effectiveness and safety of this intervention on survival with favourable neurological function after out-of-hospital cardiac arrest.

METHODS

In our randomised trial of 46 emergency medical service agencies (serving 2·3 million people) in urban, suburban, and rural areas of the USA, we assessed outcomes for patients with out-of-hospital cardiac arrest according to Utstein guidelines. We provisionally enrolled patients to receive standard CPR or active compression-decompression CPR with augmented negative intrathoracic pressure (via an impedance-threshold device) with a computer-generated block randomisation weekly schedule in a one-to-one ratio. Adults (presumed age or age ≥18 years) who had a non-traumatic arrest of presumed cardiac cause and met initial and final selection criteria received designated CPR and were included in the final analyses. The primary endpoint was survival to hospital discharge with favourable neurological function (modified Rankin scale score of ≤3). All investigators apart from initial rescuers were masked to treatment group assignment. This trial is registered with ClinicalTrials.gov, number NCT00189423.

FINDINGS

2470 provisionally enrolled patients were randomly allocated to treatment groups. 813 (68%) of 1201 patients assigned to the standard CPR group (controls) and 840 (66%) of 1269 assigned to intervention CPR received designated CPR and were included in the final analyses. 47 (6%) of 813 controls survived to hospital discharge with favourable neurological function compared with 75 (9%) of 840 patients in the intervention group (odds ratio 1·58, 95% CI 1·07-2·36; p=0·019]. 74 (9%) of 840 patients survived to 1 year in the intervention group compared with 48 (6%) of 813 controls (p=0·03), with equivalent cognitive skills, disability ratings, and emotional-psychological statuses in both groups. The overall major adverse event rate did not differ between groups, but more patients had pulmonary oedema in the intervention group (94 [11%] of 840) than did controls (62 [7%] of 813; p=0·015).

INTERPRETATION

On the basis of our findings showing increased effectiveness and generalisability of the study intervention, active compression-decompression CPR with augmentation of negative intrathoracic pressure should be considered as an alternative to standard CPR to increase long-term survival after cardiac arrest.

FUNDING

US National Institutes of Health grant R44-HL065851-03, Advanced Circulatory Systems.

Utstein style study of cardiopulmonary bypass after cardiac arrest

OBJECTIVE

The aim of this study is to describe the effect emergency cardiopulmonary bypass (CPB) for resuscitation on the survival rate of patients.

METHODS

The study population was composed of persons 16 years or older who had out-of-hospital cardiac arrest and were transferred to the Sapporo Medical University Hospital from the scene between January 1, 2000, and September 30, 2004. Children younger than 16 years and persons who were dead were excluded. Data were collected according to the Utstein style. Survival rates and cerebral performance category were analyzed using chi(2) analysis for the patients with presumed cardiac etiology. Cardiopulmonary bypass was applied to patients who showed no response with standard advanced cardiac life support. The interval from collapse and other noncardiac etiologies were considered criteria for exclusion.

RESULTS

Of the 919 patient medical records reviewed, CPB was performed in 92 patients. Of the 919 patients, 398 were of presumed cardiac etiology (n = 66 for CPB), 48 patients survived, and 24 patients (n = 7 for CPB) had a good cerebral outcome (cerebral performance category score 1). With CPB, the rate of survival at 3 months increased significantly (22.7% vs 9.9%, P < .05), but the rate of good cerebral outcome (10.6% vs 5.1%, P = .087) showed a positive trend.

CONCLUSION

The use of CPB for arrest patients was associated with reduced mortality. It did not increase good neurologic outcome significantly. Still, 7 cases with intact central nervous system would have been lost without CPB.

Out-of-hospital cardiac arrest and airborne fine particulate matter: a case-crossover analysis of emergency medical services data in Indianapolis, Indiana

BACKGROUND

Previous studies have found particulate matter (PM) < 2.5 microm in aerodynamic diameter (PM2.5) associated with heart disease mortality. Although rapid effects of PM2.5 exposure on the cardiovascular system have been proposed, few studies have investigated the effect of short-term exposures on out-of-hospital cardiac arrest (OHCA).

OBJECTIVES

We aimed to determine whether short-term PM2.5 exposures increased the risk of OHCA and whether risk depended on subject characteristics or presenting heart rhythm.

METHODS

A case-crossover analysis determined hazard ratios (HRs) for OHCAs logged by emergency medical systems (EMS) versus hourly and daily PM2.5 exposures at the time of the OHCA and for daily and hourly periods before it.

RESULTS

For all OHCAs (n = 1,374), exposures on the day of the arrest or 1-3 days before arrest had no significant effect on the incidence of OHCA. For cardiac arrests witnessed by bystanders (n = 511), OHCA risk significantly increased with PM2.5 exposure during the hour of the arrest (HR for a 10-microg/m3 increase in PM2.5 exposure = 1.12; 95% confidence interval, 1.01-1.25). For the subsets of subjects who were white, 60-75 years of age, or presented with asystole, OHCA risk significantly increased with PM2.5 during the hour of the arrest (HRs for a 10-microg/m3 increase in PM2.5 = 1.18, 1.25, or 1.22, respectively; p < 0.05). HR generally decreased as the time lag between PM2.5 exposure and OHCA increased.

CONCLUSION

The results suggest an acute effect of short-term PM2.5 exposure in precipitating OHCAs, and a need to investigate further the role of subject factors in the effects of PM on the risk of OHCA.

Calcium use during in-hospital pediatric cardiopulmonary resuscitation: a report from the National Registry of Cardiopulmonary Resuscitation

OBJECTIVES

Specific patterns of calcium use during in-hospital pediatric cardiopulmonary resuscitation have not been reported since publication of pediatric advanced life support guidelines by the American Heart Association in 2000 recommended that calcium use during cardiopulmonary resuscitation be limited to select circumstances. We hypothesized that calcium is used frequently during in-hospital pediatric cardiopulmonary resuscitation and that its use is associated with worse survival to hospital discharge.

METHODS

We reviewed 1477 consecutive pediatric cardiopulmonary resuscitation index events (for patients younger than 18 years) submitted to the National Registry of Cardiopulmonary Resuscitation from January 2000 through July 2004. The primary outcome was survival to hospital discharge. Secondary outcomes included survival of event and neurologic outcome. Multivariable logistic regression was performed to analyze the association between calcium use and outcomes.

RESULTS

Calcium was used in 659 (45%) of 1477 events. Calcium was more likely to be used during cardiopulmonary resuscitation in the settings of pediatric facilities, ICUs, cardiac surgery, cardiopulmonary resuscitation duration of > or = 15 minutes, asystole, and concurrently with other advanced life support medications: epinephrine, vasopressin, sodium bicarbonate, and magnesium sulfate. The use of calcium during cardiopulmonary resuscitation adjusted for confounding factors was associated with decreased survival to discharge and was not associated with favorable neurologic outcome.

CONCLUSIONS

Calcium is used frequently during in-hospital pediatric cardiopulmonary resuscitation. Although epidemiologic associations do not necessarily indicate causality, calcium use during cardiopulmonary resuscitation is associated with decreased survival to hospital discharge and unfavorable neurologic outcome.

A model of survival following pre-hospital cardiac arrest based on the Victorian Ambulance Cardiac Arrest Register

AIMS

This study describes the epidemiology of sudden cardiac arrest patients in Victoria, Australia, as captured via the Victorian Ambulance Cardiac Arrest Register (VACAR). We used the VACAR data to construct a new model of out-of-hospital cardiac arrest (OHCA), which was specified in accordance with observed trends.

PATIENTS

All cases of cardiac arrest in Victoria that were attended by Victorian ambulance services during the period of 2002-2005.

RESULTS

Overall survival to hospital discharge was 3.8% among 18,827 cases of OHCA. Survival was 15.7% among 1726 bystander witnessed, adult cardiac arrests of presumed cardiac aetiology, presenting in ventricular fibrillation or ventricular tachycardia (VF/VT), where resuscitation was attempted. In multivariate logistic regression analysis, bystander CPR, cardiac arrest (CA) location, response time, age and sex were predictors of VF/VT, which, in turn, was a strong predictor of survival. The same factors that affected VF/VT made an additional contribution to survival. However, for bystander CPR, CA location and response time this additional contribution was limited to VF/VT patients only. There was no detectable association between survival and age younger than 60 years or response time over 15min.

CONCLUSION

The new model accounts for relationships among predictors of survival. These relationships indicate that interventions such as reduced response times and bystander CPR act in multiple ways to improve survival.

Resuscitation in the hospital: circadian variation of cardiopulmonary arrest

PURPOSE

Over 25 reports have found outpatient frequency of sudden cardiac death peaks between 6 am and noon; few studies, with inconsistent results, have examined circadian variation of death in hospitalized patients. This study assesses circadian variation in cardiopulmonary arrest of in-hospital patients across patient, hospital, and event variables and its effect on survival to discharge.

METHODS

A retrospective, single institution registry included all admissions to the Medical Center of Central Georgia in which resuscitation was attempted between January 1987 and December 2000. The registry included 4692 admissions; only the first attempt was reported. Analyses of 1-, 2-, 4-, and 8-hour intervals were performed; 1- and 4-hour intervals are presented.

RESULTS

Significant circadian variation was found at 1 hour (P=.01), but not at 4-hour intervals. Significant circadian variation was found for initial rhythms that were perfusing (P=.03) and asystole (P=.01). A significantly higher percentage of unwitnessed events were found as asystole during the overnight hours (P=.002). Using simple logistic regression, time in 4-hour intervals and rhythm were each significantly related to patient survival until hospital discharge (P=.003 and P <.0001). In multivariate analysis, only rhythm remained significant.

CONCLUSIONS

Circadian variation of cardiopulmonary arrest in this hospital has several temporal versions and is related to survival. Late night variation in witnessed events and rhythm suggests a delay between onset of clinical death and discovery, which contributes to poorer outcomes.

Comparison of 30 and the 100% inspired oxygen concentrations during early post-resuscitation period: a randomised controlled pilot study

OBJECTIVES

High oxygen concentration in blood may be harmful in the reperfusion phase after cardiopulmonary resuscitation. We compared the effect of 30 and 100% inspired oxygen concentrations on blood oxygenation and the level of serum markers (NSE, S-100) of neuronal injury during the early post-resuscitation period in humans.

METHODS

Patients resuscitated from witnessed out-of-hospital ventricular fibrillation were randomised after the return of spontaneous circulation (ROSC) to be ventilated either with 30% (group A) or 100% (group B) oxygen for 60 min. Main outcome measures were NSE and S-100 levels at 24 and 48 h after ROSC, the adequacy of oxygenation at 10 and 60 min after ROSC and, in group A, the need to raise FiO(2) to avoid hypoxaemia. Blood oxygen saturation <95% was the threshold for this intervention.

RESULTS

Thirty-two patients were randomised and 28 (14 in group A and 14 in group B) remained eligible for the final analysis. The mean PaO(2) at 10 min was 21.1 kPa in group A and 49.7 kPa in group B. The corresponding values at 60 min were 14.6 and 46.5 kPa. PaO(2) values did not fall to the hypoxaemic level in group A. In another group FiO(2) had to be raised in five cases (36%) but in two cases it was returned to 0.30 rapidly. The mean NSE at 24 and 48 h was 10.9 and 14.2 microg/l in group A and 13.0 and 18.6 microg/l in group B (ns). S-100 at corresponding time points was 0.21 and 0.23 microg/l in group A and 0.73 and 0.49 microg/l in group B (ns). In the subgroup not treated with therapeutic hypothermia in hospital NSE at 24h was higher in group B (mean 7.6 versus 13.5 microg/l, p=0.0487).

CONCLUSIONS

Most patients had acceptable arterial oxygenation when ventilated with 30% oxygen during the immediate post-resuscitation period. There was no indication that 30% oxygen with SpO(2) monitoring and oxygen backup to avoid SpO(2)<95% did worse that the group receiving 100% oxygen. The use of 100% oxygen was associated with increased level of NSE at 24h in patients not treated with therapeutic hypothermia. The clinical significance of this finding is unknown and an outcome-powered study is feasible.

Emergency call processing and survival from out-of-hospital ventricular fibrillation

OBJECTIVES

Our aim was to report the effect of the emergency call processing in the dispatching centre on survival from out-of-hospital ventricular fibrillation (VF).

METHODS

This retrospective cohort study was conducted in Helsinki Emergency Medical Services. All consecutive cases with out-of-hospital bystander witnessed VF of cardiac origin between 1 January 1997 and 31 December 2002 were included. Data were collected prospectively. Call processing times, call numbers per dispatcher and telephone guided cardiopulmonary resuscitation (CPR) were studied. Discharge alive from hospital was used as primary end point.

RESULTS

The study population consisted of 373 cases. Cardiac arrest (CA) was recognised in 296 cases (79.4%) by the dispatcher. Survival to discharge was 37.2% (110/296) if CA was recognised and 28.6% (22/77) if it was not recognised (p=0.1550). When the dispatcher handled <4 VF calls during the study period survival to discharge was 22.1% (17/77) compared to 38.2% (50/131) and 39.4% (65/165) when the call volume was 4-9 or >9 (p=0.0227). The mean time to dispatch a first responding unit (FRU) was 77.1+/-44.3 s. Survival to discharge was 39.4% (65/165) when the FRU dispatching time was <60s and 32.2% (67/208) when dispatching took > or =60 s (p=0.1496). The mean time to CA recognition was 170.2+/-130.1 s. Spontaneous circulation was achieved more rapidly when the time was <150 s (p=0.0426), but there was no difference in survival to discharge. Telephone guided CPR instructions were given in 123 cases (35.5%). Survival to discharge was 43.1% (53/123) when CPR instructions were given and 31.7% (72/223) when they were not given (p=0.0453).

CONCLUSIONS

We showed that low CA call numbers per dispatcher is associated with a decreased probability of survival. Giving telephone guided CPR instructions should be promoted as they influence the outcome. Further studies are needed to determine optimal call processing times.

Predictors and outcome of cardiopulmonary resuscitation (CPR) calls in a large haemodialysis unit over a seven-year period

BACKGROUND

Cardiac mortality is the leading cause of death in dialysis patients, with cardiac arrests being most frequent. Our purpose was to determine the epidemiology, predictors and outcomes of calls for cardiopulmonary resuscitation (CPR) occurring in our haemodialysis unit.

METHODS

We reviewed retrospectively all calls for CPR occurring in our unit between August 1997 and December 2004 and compared data to a cohort of chronic haemodialysis patients from our unit. Dialysis sessions performed in the ICUs were not included.

RESULTS

A total of 38 calls occurred over 307,553 sessions, corresponding to an incidence of 0.012%. In a multivariate logistic regression model, statistically significant predictors to have a call for CPR were ischaemic heart disease (OR: 3.93; 95% CI: 1.70-9.07), heart failure (OR: 2.74; 95% CI: 1.12-6.74) and female gender (OR: 2.96; 95% CI: 1.37-6.43). Patients who had a call for CPR had a lower dialysis vintage than control patients (OR: 0.98; 95% CI: 0.965-0.996). Twenty of the 38 events presented on Mondays or Tuesdays (P = 0.012); 78% occurred during haemodialysis, vs 14 and 8% immediately after and immediately before dialysis but still on the unit, respectively. Of the 38 events, 24 were true cardiopulmonary arrests. Cardiac etiology was the most frequent (34%) and only 4 events were attributed to potassium disorders. One quarter of patients were dialyzed against a dialysate potassium concentration of 1 mmol/l or below. An arrhythmia was identified in 19 patients; a malignant ventricular fibrillation or ventricular tachycardia was most frequently found (32%), followed by severe bradycardia (26%). For the whole group, there were 6 deaths (16%) within 48 h; 30 patients (79%) were alive at 30 days and discharged from the hospital. Among the 24 cardiopulmonary arrests, there were 4 deaths (17%) within 48 h; 18 patients (75%) were alive at 30 days and discharged from the hospital. There was a trend for worse prognosis at 60 days when related to cardiopulmonary etiology (P = 0.054) and when a true cardiopulmonary arrest occurred (P = 0.134).

CONCLUSIONS

This study confirms that arrest codes occur more frequently on Mondays and Tuesdays in a haemodialysis unit. Survival after an arrest code appears to be better than in certain other circumstances, probably in part because of the presence of witness, physician and equipment, and vascular access being readily available.