体外心肺复苏技术在成人心搏骤停抢救中的应用

目的 回顾性总结应用体外心肺复苏(E-CPR)技术救治成人心搏骤停患者的临床经验.方法 2005年7月至2009年7月,有11例心源性心搏骤停成人患者(男7例,女4例,年龄24～71岁)经常规心肺复苏(CPR)抢救10～15 min无法有效恢复自主循环,而采用E-CPR技术抢救.7例心脏手术后患者在CPR抢救同时自原胸骨切口先建立升主动脉-右心房常规体外循环辅助,再转为体外膜肺氧合(ECMO)辅助;4例患者在CPR抢救同时直接经股动、静脉置管建立ECMO辅助.结果 11例患者CPR时间30～90 min,平均(51±14)min,10例患者可恢复自主心律.11例患者ECMO辅助时间2～223 h,中位时间126 h.6例患者成功撤离ECMO辅助,但存活出院率为36.4%(4/11).2例患者在ECMO辅助的同时加用主动脉内球囊反搏术(IABP),1例存活.3例患者因合并肾功能衰竭而需血液滤过治疗.结论 E-CPR为抢救危重的心搏骤停患者提供了一个新的手段.如何有效评估和选择病例,及时开始救治以提高成功率,值得进一步研究.     

Comparison of out-of-hospital cardiac arrest occurring before and after paramedic arrival: Epidemiology,survival to hospital discharge and 12-month functional recovery

BackgroundDespite immediate resuscitation, survival rates following out-of-hospital cardiac arrests (OHCA) witnessed by emergency medical service (EMS) are reportedly low. We sought to compare survival and 12-month functional recovery outcomes for OHCA occurring before and after EMS arrival.MethodsBetween 1st July 2008 and 30th June 2013, we included 8648 adult OHCA cases receiving an EMS attempted resuscitation from the Victorian Ambulance Cardiac Arrest Registry, and categorised them into five groups: bystander witnessed cases ± bystander CPR, unwitnessed cases ± bystander CPR, and EMS witnessed cases. The main outcomes were survival to hospital and survival to hospital discharge. Twelve-month survival with good functional recovery was measured in a sub-group of patients using the Extended Glasgow Outcome Scale (GOSE).ResultsBaseline and arrest characteristics differed significantly across groups. Unadjusted survival outcomes were highest among bystander witnessed cases receiving bystander CPR and EMS witnessed cases, however outcomes differed significantly between these groups: survival to hospital (46.0% vs. 53.4% respectively, p < 0.001); survival to hospital discharge (21.1% vs. 34.9% respectively, p < 0.001). When compared to bystander witnessed cases receiving bystander CPR, EMS witnessed cases were associated with a significant improvement in the risk adjusted odds of survival to hospital (OR 2.02, 95% CI: 1.75–2.35), survival to hospital discharge (OR 6.16, 95% CI: 5.04–7.52) and survival to 12 months with good functional recovery (OR 5.56, 95% CI: 4.18–7.40).ConclusionWhen compared to OHCA occurring prior to EMS arrival, EMS witnessed arrests were associated with significantly higher survival to hospital discharge rates and favourable neurological recovery at 12-month post-arrest.     

Exploring which patients without return of spontaneous circulation following ventricular fibrillation out-of-hospital cardiac arrest should be transported to hospital?

Background

Currently many emergency medical services (EMS) that provide advanced cardiac life support (ACLS) at scene do not routinely transport out-of-hospital cardiac arrest (OHCA) patients without sustained return of spontaneous circulation (ROSC). This is due to logistical difficulties and historical poor outcomes. However, new technology for mechanical chest compression has made transport to hospital safer and extracorporeal membrane oxygenation during cardiopulmonary resuscitation (ECPR) enabling further intervention, may result in ROSC. We aimed to explore the characteristics and outcomes of patients with OHCA who were transported to hospital with ongoing CPR in the absence of ROSC, who might benefit from this new technology.

Methods and results

The Victorian Ambulance Cardiac Arrest Registry (VACAR) was searched for adult OHCA with an initial shockable rhythm between 2003 and 2012. There were 5593 OHCA meeting inclusion criteria. Analysis was performed on 3095 (55%) of patients who did not achieve sustained ROSC in the field. Of these only 589 (20%) had ongoing CPR to hospital. There was a significant decline in rates of transport over the study period. Predictors of transport with ongoing CPR included younger patients, decreased time to first shock and intermittent ROSC prior to transport. Survival to hospital discharge occurred in 52 (9%) of patients who had ongoing CPR to hospital.

Conclusion

In an EMS that provides ACLS at scene, patients without ROSC in the field who receive CPR to hospital have poor outcomes. Developing a system which provides safe transport with ongoing CPR to a hospital that provides ECPR, should be considered.     

Treatment and outcome of out-of-hospital cardiac arrest in outpatient health care facilities

AimWe evaluated the frequency and effectiveness of basic and advanced life support (ALS) interventions by medical professionals when out-of-hospital cardiac arrest (OHCA) occurred in ambulatory healthcare clinics before emergency medical services (EMS) arrival.MethodsNon-traumatic OHCAs in adults were systematically characterized over a 15 year period by their occurrence in clinics, at home, or in non-medical public locations, and outcomes compared between matched cohorts from each group.ResultsAmong 7784 patients, 6098 OHCA occurred at home, 1612 in non-medical public locations and 74 in clinics. Compared to non-medical public locations, clinic patients with OHCA were older, more often women and more frequently shocked; clinic arrests were more often witnessed, less likely to be of cardiac cause and to occur before EMS arrival. Compared to home, more clinic arrests were witnessed, occurred after EMS arrival, had bystander CPR, shockable rhythms and were defibrillated. When OHCA occurred before EMS arrival, 51 of 56 clinic patients (91%) received CPR, a defibrillator applied to 23 (41%), 17 (30%) were shocked, 4 (7%) intubated, and 7 (13%) received intravenous medications from facility personnel. Of these, only pre-EMS defibrillator use was associated with improved outcome. Among matched patients, OHCA survival was higher in clinics than at home (42% vs 26%, p = 0.029), but comparable to other public locations.ConclusionsSurvival from OHCA in clinics was comparable to non-medical public locations, and higher than at home. Alongside CPR, use of defibrillators was associated with improved survival and worth prioritizing over other interventions before EMS arrival regardless of OHCA location.     

Survival models for out-of-hospital cardiopulmonary resuscitation from the perspectives of the bystander, the first responder, and the paramedic.

Survival from out-of-hospital resuscitation depends on the strength of each component of the chain of survival. We studied, on the scene, witnessed, nontraumatic resuscitations of patients older than 17 years. The influence of the chain of survival and potential predictors on survival was analyzed by logistic regression modeling. From 1030 patients, 139 survived to hospital discharge. Three prediction models of survival were developed from the perspective of the different contributors active in out-of-hospital resuscitation: model I, bystanders; model II, first responders; and model III, paramedics. Predictors for survival (with odds ratio) were: in model I (bystanders): emergency medical service (EMS) witnessed arrest (0.50), delay to basic cardiopulmonary resuscitation (CPR) (0.74/min) and delay to EMS arrival (0.87/min); in model II (first responders): initial recorded heart rhythm (0.02 for nonshockable rhythm), delay to basic CPR (0.71/min and 0.87/min for shockable and nonshockable rhythms) and to defibrillation (0.89/min), and in model III (paramedics): need for advanced CPR (4.74 for advanced CPR not-needed), initial recorded heart rhythm (0.05 for nonshockable rhythm), and delay to basic CPR (0.77/min and 0.72/min for shockable and nonshockable rhythms), to defibrillation and to advanced CPR for shockable rhythms (0.85/min), and to advanced CPR for nonshockable rhythm (0.85/min). The area under the receiver-operator characteristic curve for model I was 0.763, for model II was 0.848, and for model III was 0.896. Of survivors, 50% had restoration of circulation without need for advanced CPR. Three survival models for witnessed nontraumatic out-of-hospital resuscitation based on the information known by bystanders, first responders and paramedics explained survival with increasing precision. Early defibrillation can restore circulation without the need for advanced CPR. When advanced CPR is needed, its delay leads to a markedly reduced survival.     

No Benefit in Neurologic Outcomes of Survivors of Out-of-Hospital Cardiac Arrest with Mechanical Compression Device

Introduction: Out-of-hospital cardiac arrest (OHCA) is a major cause of death and morbidity in the United States. Quality cardiopulmonary resuscitation (CPR) has proven to be a key factor in improving survival. The aim of our study was to investigate the outcomes of OHCA when mechanical CPR (LUCAS 2 Chest Compression System?) was utilized compared to conventional CPR. Although controlled trials have not demonstrated a survival benefit to the routine use of mechanical CPR devices, there continues to be an interest for their use in OHCA. Methods: We conducted a retrospective observational study of OHCA comparing the outcomes of mechanical and manual chest compressions in a fire department based EMS system serving a population of 1.4 million residents. Mechanical CPR devices were geographically distributed on 11 of 33 paramedic ambulances. Data were collected over a 36-month period and outcomes were dichotomized based on utilization of mechanical CPR. The primary outcome measure was survival to hospital discharge with a cerebral performance category (CPC) score of 1 or 2. Results: This series had 3,469 OHCA reports, of which 2,999 had outcome data and met the inclusion criteria. Of these 2,236 received only manual CPR and 763 utilized a mechanical CPR device during the resuscitation. Return of spontaneous circulation (ROSC) was attained in 44% (334/763) of the mechanical CPR resuscitations and in 46% (1,020/2,236) of the standard manual CPR resuscitations (p = 0.32). Survival to hospital discharge was observed in 7% (52/763) of the mechanical CPR resuscitations and 9% (191/2,236) of the manual CPR group (p = 0.13). Discharge with a CPC score of 1 or 2 was observed in 4% (29/763) of the mechanical CPR resuscitation group and 6% (129/2,236) of the manual CPR group (p = 0.036). Conclusions: In our study, use of the mechanical CPR device was associated with a poor neurologic outcome at hospital discharge. However, this difference was no longer evident after logistic regression adjusting for confounding variables. Resuscitation management following institution of mechanical CPR, specifically medication and airway management, may account for the poor outcome reported. Further investigation of resuscitation management when a mechanical CPR device is utilized is necessary to optimize survival benefit.     

Factors affecting short- and long-term prognosis among 1069 patients with out-of-hospital cardiac arrest and pulseless electrical activity.

AIMS: To describe the epidemiology, resuscitation factors and prognosis among a consecutive population of patients suffering from out-of-hospital cardiac arrest (OHCA) where pulseless electrical activity (PEA) was the first arrhythmia recorded on emergency medical services (EMS) arrival. METHODS: Analysis of data collected prospectively on all patients regardless of age succumbing to OHCA during 1980-1997 in the community of Gothenburg where EMS initiated resuscitative measures. RESULTS: 4662 patients with OHCA were attended by the EMS during the study period. Of these, 1069 (23%) were judged as having PEA as the first recorded arrhythmia; 158 (15%) of these were admitted alive to hospital and 26 (2.4%) were discharged alive. Survivors to discharge had a significantly larger share of bystander cardiopulmonary resuscitation (CPR) (28 vs. 8%, P=0.008), significantly higher levels of consciousness (8% awake vs. 0%, P<0.001) and higher median systolic blood pressure (145 vs. 106 mmHg, P<0.001) on arrival at hospital. No patient with unwitnessed cardiac arrest and PEA over 80 years old survived. CONCLUSION: Survival among patients suffering from OHCA and PEA is poor, especially among the elderly unwitnessed cases and those who do not receive bystander CPR. The latter seems to be of utmost importance among these patients.     

Establishing Arizona's Statewide Cardiac Arrest Reporting andEducational Network

Background. Only a few large cities have published their out-of-hospital cardiac arrest (OHCA) survival statistics using the Utstein style reporting method. To date, to the best of our knowledge there has been no published OHCA survival data for a state. Objective. To describe the process, benefits, andchallenges of establishing a statewide OHCA database andeducational network. Methods. Arizona's Bureau of Emergency Medical Services andTrauma System initiated a statewide, prospective, observational cohort review of all OHCA victims on whom resuscitation was attempted in the field. Emergency medical services (EMS) first care reports, voluntarily submitted by 35 departments in Arizona, were analyzed. We chronicled the development of our data-collection process along with how we obtained patient outcomes anddelivered feedback to field providers. Entry data included time intervals andnodal events conforming to the Utstein style template. Results. In data collected between January 1, 2005, andApril 1, 2006, there were 1,484 OHCAs reported, of which 1,104 were of presumed cardiac etiology occurring prior to EMS arrival. The OHCA incidence was approximately 0.44 per 1,000 population per year. In our database, bystander CPR provided an odds ratio of 3.0 for survival (95% confidence interval 1.3, 6.7). Outcomes for 1,076 patients were obtained. Thirty-seven (3.4%) of the 1,076 cardiac arrest victims survived to hospital discharge. Twenty-seven (8.6%) of the 331 ventricular fibrillation cardiac arrest victims survived to hospital discharge. Conclusion. It is feasible for a public health agency to implement a voluntary, statewide data-collection system andeducational network to determine andimprove survival from OHCA.     

Impact of rapid response car system on ECMO in out-of-hospital cardiac arrest: A retrospective cohort study

Introduction

Extracorporeal life support (ECLS) has been reported to be more effective than conventional cardiopulmonary resuscitation (CPR). In ECLS, a shorter time from arrival to implantation of extracorporeal membrane oxygenation (ECMO; door-to-ECMO) time was predicted to be associated with better survival rates. This study aimed to examine the impact of the physician-based emergency medical services (P-EMS) using a rapid response car (RRC) on door-to-ECMO time in patients with out-of-hospital cardiac arrest (OHCA).

Traumatic out-of-hospital cardiac arrests in Melbourne, Australia

Introduction

Many consider attempted resuscitation for traumatic out-of-hospital cardiac arrest (OHCA) futile. This study aims to describe the characteristics and profile of adult traumatic OHCA.

Methods

The Victorian Ambulance Cardiac Arrest Registry (VACAR) was used to identify all trauma related cases of OHCA in patients aged ≥16 years.

Results

Between 2000 and 2009, EMS attended 33,178 OHCAs of which 2187 (6.6%) had a traumatic aetiology. The median age (IQR) of traumatic OHCA cases was 36 (25–55) years and 1612 were male (77.5%). Bystander CPR was performed in 201 cases (10.2%) with median (IQR) EMS response time 8 (6–11) min. The first recorded rhythm by EMS was asystole seen in 1650 (75.4%), PEA in 294 (13.4%) cases and VF in 35 cases (1.6%). Cardiac output was present in 208 (9.5%) cases who subsequently had an EMS witnessed OHCA. EMS attempted resuscitation in 545 (24.9%) patients of whom 84 (15.4%) achieved ROSC and were transported, and 27 (5.1%) survived to hospital discharge; 107 were transported with CPR of whom 8 (7.4%) survived to hospital discharge. Where EMS attempted resuscitation in traumatic OHCAs, survival for VF was 11.8% (n = 4), PEA 5.1% (n = 10) and asystole 2.4% (n = 3). In EMS witnessed traumatic OHCA, resuscitation was attempted in 175 cases (84.1%), 35 (16.8%) patients achieved sustained ROSC before transport of whom 5 (14%) survived to leave hospital and 60 (28.8%) were transported with CPR of whom 6 (10%) survived to leave hospital. Compared to OHCA cases with ‘presumed cardiac’ aetiology traumatic OHCAs were younger [median years (IQR): 36 (25–55) vs 74 (61–82)], had resuscitation attempted less (25% vs 48%), were less likely to have a shockable rhythm (1.6% vs 17.1%), were more likely to be witnessed (62.8% vs 38.1%) and were less likely to receive bystander CPR (10.2% vs 25.5%) (p < 0.001, respectively). Multivariate logistic regression identified factors associated with EMS decision to attempt resuscitation. The odds ratio [OR (95% CI)] for ‘presence of bystander CPR’ was 5.94 (4.11–8.58) and for ‘witnessed arrest’ was 2.60 (1.86–3.63).

Conclusion

In this paramedic delivered EMS attempted resuscitation was not always futile in traumatic OHCA with a survival of 5.1%. The quality of survival needs further study.     

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

Aim

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

Methods

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

Results

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

Conclusion

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

Relationship between Time-to-ROSC and Survival in Out-of-hospital Cardiac Arrest ECPR Candidates: When is the Best Time to Consider Transport to Hospital?

Objective: Extracorporeal cardiopulmonary resuscitation (ECPR) may improve outcomes for refractory out-of-hospital cardiac arrest (OHCA). Transport of intra-arrest patients to hospital however, may decrease CPR quality, potentially reducing survival for those who would have achieved return-of-spontaneous-circulation (ROSC) with further on-scene resuscitation. We examined time-to-ROSC and patient outcomes for the optimal time to consider transport. Methods: From a prospective registry of consecutive adult non-traumatic OHCA's, we identified a hypothetical ECPR-eligible cohort of EMS-treated patients with age ≤ 65, witnessed arrest, and bystander CPR or EMS arrival < 10 minutes. We assessed the relationship between time-to-ROSC and survival, and constructed a ROC curve to illustrate the ability of a pulseless state to predict non-survival with conventional resuscitation. Results: Of 6,571 EMS-treated cases, 1,206 were included with 27% surviving. Increasing time–to–ROSC (per minute) was negatively associated with survival (adjusted OR 0.91; 95%CI 0.89–0.93%). The yield of survivors per minute of resuscitation increased from commencement and started to decline in the 8th minute. Fifty percent and 90% of survivors had achieved ROSC by 8.0 and 24 min, respectively, at which times the probability of survival for those with initial shockable rhythms was 31% and 10%, and for non-shockable rhythms was 5.2% and 1.6%. The ROC curve illustrated that the 16th minute of resuscitation maximized sensitivity and specificity (AUC = 0.87, 95% CI 0.85–0.89). Conclusion: Transport for ECPR should be considered between 8 to 24 minutes of professional on-scene resuscitation, with 16 minutes balancing the risks and benefits of early and later transport. Earlier transport within this window may be preferred if high quality CPR can be maintained during transport and for those with initial non-shockable rhythms.     

Prognostic implications of conversion from nonshockable to shockable rhythms in out-of-hospital cardiac arrest

Introduction

The prognostic significance of conversion from nonshockable to shockable rhythms in patients with initial nonshockable rhythms who experience out-of-hospital cardiac arrest (OHCA) remains unclear. We hypothesized that the neurological outcomes in those patients would improve with subsequent shock delivery following conversion to shockable rhythms and that the time from initiation of cardiopulmonary resuscitation by emergency medical services personnel to the first defibrillation (shock delivery time) would influence those outcomes.

Methods

We analyzed the data of 569,937 OHCA adults with initial nonshockable rhythms. The data were collected in a nationwide Utstein-style Japanese database between 2005 and 2010. Patients were divided into subsequently shocked (n =21,944) and subsequently not-shocked (n =547,993) cohorts. The primary study endpoint was 1-month favorable neurological outcome (Cerebral Performance Categories scale, category 1 or 2).

Results

In the subsequently shocked cohort, the ratio of 1-month favorable neurological outcome was significantly higher than that in the subsequently not-shocked cohort (1.79% versus 0.60%, P <0.001). Multivariate logistic regression analysis for 11 prehospital variables revealed that when the shock delivery time was less than 20 minutes, subsequent shock delivery was significantly associated with increased odds of 1-month favorable neurological outcomes (adjusted odds ratios (95% confidence interval), 6.55 (5.21 to 8.22) and 2.97 (2.58 to 3.43) for shock delivery times less than 10 minutes and from 10 to 19 minutes, respectively). However, when the shock delivery time was more than or equal to 20 minutes, subsequent shock delivery was not associated with increased odds of 1-month favorable neurological outcomes.

Conclusions

In patients with an initial nonshockable rhythm after OHCA, subsequent conversion to shockable rhythms during emergency medical services resuscitation efforts was associated with increased odds of 1-month favorable neurological outcomes when the shock delivery time was less than 20 minutes.     

Outcomes for out-of-hospital cardiac arrests across 7 countries in Asia: The Pan Asian Resuscitation Outcomes Study (PAROS)

BackgroundThe Pan Asian Resuscitation Outcomes Study (PAROS) Clinical Research Network (CRN) was established in collaboration with emergency medical services (EMS) agencies and academic centers in Japan, Singapore, South Korea, Malaysia, Taiwan, Thailand, and UAE-Dubai and aims to report out-of-hospital cardiac arrests (OHCA) and provide a better understanding of OHCA trends in Asia.Methods and resultsThis is a prospective, international, multi-center cohort study of OHCA across the Asia-Pacific. Each participating country provided between 1.5 and 2.5 years of data from January 2009 to December 2012. All OHCA cases conveyed by EMS or presenting at emergency departments were captured.66,780 OHCA cases were submitted to the PAROS CRN; 41,004 cases were presumed cardiac etiology. The mean age OHCA occurred varied from 49.7 to 71.7 years. The proportion of males ranged from 57.9% to 82.7%. Proportion of unwitnessed arrests ranged from 26.4% to 67.9%. Presenting shockable rhythm rates ranged from 4.1% to 19.8%. Bystander cardiopulmonary resuscitation (CPR) rates varied from 10.5% to 40.9%, however <1.0% of these arrests received bystander defibrillation. For arrests that were with cardiac etiology, witnessed arrest and VF, the survival rate to hospital discharge varied from no reported survivors to 31.2%. Overall survival to hospital discharge varied from 0.5% to 8.5%. Survival with good neurological function ranged from 1.6% to 3%.ConclusionsSurvival to hospital discharge for Asia varies widely and this may be related to patient and system differences. This implies that survival may be improved with interventions such as increasing bystander CPR, public access defibrillation and improving EMS.     

Neurological Favorable Outcomes Associated with EMS Compliance and On-Scene Resuscitation Time Protocol

Purpose: Korean national emergency care protocol for EMS providers recommends a minimum of 5 minutes of on-scene resuscitation before transport to hospital in cases of Out-of-Hospital Cardiac Arrest (OHCA). We compared survival outcome of OHCA patients according to scene time interval (STI)-protocol compliance of EMS. Methods: EMS treated adult OHCAs with presumed cardiac etiology during a two-year period were analyzed. Non-compliance was defined as hospital transport with STI less than 6 minutes without return of spontaneous circulation (ROSC) on scene. Propensity score for compliance with protocol was calculated and based on the calculated propensity score, 1:1 matching was performed between compliance and non-compliance group. Univariate analysis as well as multivariable logistic model was used to evaluate the effect of compliance to survival outcome. Results: Among a total of 28,100 OHCAs, EMS transported 7,026 (25.0%) cardiac arrests without ROSC on the scene with an STI less than 6 minutes. A total of 6,854 cases in each group were matched using propensity score matching. Overall survival to discharge rate did not differ in both groups (4.6% for compliance group vs. 4.5 for non-compliance group, p = 0.78). Adjusted odds ratio of compliance for survival to discharge were 1.12 (95% CI 0.92–1.36). More patients with favorable neurological outcome was shown in compliance group (2.5% vs. 1.7%, p < 0.01) and adjusted odds ratio was 1.91 (95% CI 1.42–2.59). Conclusions: Although survival to discharge rate did not differ for patient with EMS non-compliance with STI protocol, lesser patients survived with favorable neurological outcomes when EMS did not stay for sufficient time on scene in OHCA before transport.     

Resuscitation of out-of-hospital cardiac arrests in residential aged care facilities in Melbourne, Australia

Introduction

CPR in patients in residential aged care facilities (RACF) deserves careful consideration. We examined the characteristics, management and outcomes of out-of-hospital cardiac arrest (OHCA) in RACF patients in Melbourne, Australia.

Methods

The Victorian Ambulance Cardiac Arrest Registry (VACAR) was searched for all OHCAs occurring in RACFs in Melbourne. The characteristics and outcomes were compared to non-RACF patients in the VACAR.

Results

Between 2000 and 2009 there were 30,006 OHCAs, 2350 (7.8%) occurring in a RACF.A shockable rhythm was present in 179 (7.6%) patients on arrival of paramedics of whom bystander CPR had been performed in 118 (66%); 173 (97%) received an EMS attempted resuscitation. ROSC was achieved in 71 (41%) patients and 15 (8.7%) patients survived to leave hospital. Non shockable rhythm was present in 2171 patients (92%) of whom 804 (37%) had an attempted resuscitation by paramedics. ROSC was achieved in 176 patients (22%) and 10 patients (1.2%) were discharged alive. Survival from OHCA occurring in a RACF was less than survival in those aged >70 years of age who suffered OHCA in their own homes (1.8% vs. 4.7%, p = 0.001). On multivariable analysis, witnessed OHCA (OR 3.0, 95% CI 2.4-3.7) and the presence of bystander CPR (OR 4.6, 95% CI 3.7-5.8) was associated with the paramedic decision to resuscitate.

Conclusion

Resuscitation of patients in RACF is not futile. However, informed decisions concerning resuscitation status should be made by patients and their families on entry to a RACF. Where it is appropriate to perform resuscitation, outcomes may be improved by the provision of BLS training and possibly AED equipment to RACF staff.     

Managing cardiac arrest with refractory ventricular fibrillation in the emergency department: Conventional cardiopulmonary resuscitation versus extracorporeal cardiopulmonary resuscitation

AimRefractory ventricular fibrillation, resistant to conventional cardiopulmonary resuscitation (CPR), is a life threatening rhythm encountered in the emergency department. Although previous reports suggest the use of extracorporeal CPR can improve the clinical outcomes in patients with prolonged cardiac arrest, the effectiveness of this novel strategy for refractory ventricular fibrillation is not known. We aimed to compare the clinical outcomes of patients with refractory ventricular fibrillation managed with conventional CPR or extracorporeal CPR in our institution.MethodThis is a retrospective chart review study from an emergency department in a tertiary referral medical center. We identified 209 patients presenting with cardiac arrest due to ventricular fibrillation between September 2011 and September 2013. Of these, 60 patients were enrolled with ventricular fibrillation refractory to resuscitation for more than 10 min. The clinical outcome of patients with ventricular fibrillation received either conventional CPR, including defibrillation, chest compression, and resuscitative medication (C-CPR, n = 40) or CPR plus extracorporeal CPR (E-CPR, n = 20) were compared.ResultsThe overall survival rate was 35%, and 18.3% of patients were discharged with good neurological function. The mean duration of CPR was longer in the E-CPR group than in the C-CPR group (69.90 ± 49.6 min vs 34.3 ± 17.7 min, p = 0.0001). Patients receiving E-CPR had significantly higher rates of sustained return of spontaneous circulation (95.0% vs 47.5%, p = 0.0009), and good neurological function at discharge (40.0% vs 7.5%, p = 0.0067). The survival rate in the E-CPR group was higher (50% vs 27.5%, p = 0.1512) at discharge and (50% vs 20%, p = 0. 0998) at 1 year after discharge.ConclusionsThe management of refractory ventricular fibrillation in the emergency department remains challenging, as evidenced by an overall survival rate of 35% in this study. Patients with refractory ventricular fibrillation receiving E-CPR had a trend toward higher survival rates and significantly improved neurological outcomes than those receiving C-CPR.     

Improvements in Out-of-Hospital Cardiac Arrest Survival from 1998 to 2013

Objectives: Out-of-hospital cardiac arrest (OHCA) remains a major public health burden. Aggregate OHCA survival to hospital discharge has reportedly remained unchanged at 7.6% for almost 30 years from 1970 to 2008. We examined the trends in adult OHCA survival over a 16-year period from 1998 to 2013 within a single EMS agency. Methods: Observational cohort study of adult OHCA patients treated by Tualatin Valley Fire & Rescue (TVF&R) from 1998 to 2013. This is an ALS first response fire agency that maintains an active Utstein style cardiac arrest registry and serves a population of approximately 450,000 in 9 incorporated cities in Oregon. Primary outcomes were survival to hospital discharge in all patients and in the subgroup with witnessed ventricular fibrillation/pulseless ventricular tachycardia (VF/VT). The impact of key covariates on survival was assessed using univariate logistic regression. These included patient factors (age and sex), event factors (location of arrest, witnessed status, and first recorded cardiac arrest rhythm), and EMS system factors (response time interval, bystander CPR, and non-EMS AED shock). We used multivariate logistic regression to examine the impact of year increment on survival after multiple imputation for missing data. Sensitivity analysis was performed with complete cases. Results: During the study period, 2,528 adult OHCA had attempted field resuscitation. The survival rate for treated cases increased from 6.7% to 18.2%, with witnessed VF/VT cases increasing from 14.3% to 31.4% from 1998 to 2013. Univariate analysis showed that younger age, male sex, public location of arrest, bystander or EMS witnessed event, initial rhythm of pulseless electrical activity (PEA) or VF/VT, bystander CPR, non-EMS AED shock, and a shorter EMS response time were independently associated with survival. After adjustment for covariates, the odds of survival increased by 9% (OR 1.09, 95%CI: 1.05–1.12) per year in all treated cases, and by 6% (OR 1.06, 95% 1.01–1.10) per year in witnessed VF/VT subgroups. Findings remained consistent on sensitivity analysis. Conclusions: Overall survival from treated OHCA has increased over the last 16 years in this community. These survival increases demonstrate that OHCA is a treatable condition that warrants further investigation and investment of resources.     

Outcome of avalanche victims with out-of-hospital cardiac arrest

Study backgroundPrevious studies focused on the outcome of avalanche victims with out-of-hospital cardiac arrest (OHCA) after long duration of burial (>35 min); the outcome of victims with short duration (≤35 min) remains obscure.Aim of the studyTo investigate outcome of avalanche victims with OHCA.MethodsRetrospective analysis of avalanche victims with OHCA between 2008 and 2013 in the Tyrolean Alps.Results55 avalanche victims were identified, 32 of whom were declared dead after extrication without cardiopulmonary resuscitation (CPR), all with long duration of burial. In the remaining 23 CPR was initiated at scene; three were partially and 20 completely buried, nine of whom suffered short and 11 long duration of burial. All nine victims with short duration of burial underwent restoration of spontaneous circulation (ROSC) at scene, four of them after bystander CPR, five after advanced life support by the emergency physician. Two patients with ROSC after short duration of burial and bystander CPR survived to hospital discharge with cerebral performance category 1. None of the 11 victims with long duration of burial survived to hospital discharge, although six were transported to hospital with ongoing CPR and three were supported with extracorporeal circulation.ConclusionsIn this case series survival with favourable neurological outcome was observed in avalanche victims with short duration of burial only if bystander CPR was immediately performed and ROSC achieved. Strategies for reducing avalanche mortality should focus on prompt extrication from the snow and immediate bystander CPR by uninjured companions.