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.     

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.     

Outcome of out-of-hospital cardiac arrest over a period of 15 years in comparison to the RACA score in a physician staffed urban emergency medical service in Germany

BackgroundPatient outcome after out of hospital cardiac arrest (OHCA) depends on the cardiopulmonary resuscitation (CPR) performance and might also be influenced by organisation of the emergency medical service (EMS) and implementation of guidelines.AimTo assess the rate of return of spontaneous circulation (ROSC) after cardiac arrest to the predicted rate by the ROSC after cardiac arrest (RACA) score over a 15-year period reflecting three different implemented ALS-guidelines in a physician-staffed EMS.MethodsAll adult patients with non-traumatic OHCA in the EMS of Bonn from 1996 to 2011 were included. Utstein data from three 5-years time periods (1996–2001, 2001–2006, 2006–2011) representing different ALS-guideline implementations were collected. Group comparisons were made in terms of incidence, epidemiology and short-term outcome of CPR with emphasis on changes over time and factors of importance. In each group observed ROSC rate were compared to the predicted ROSC rates (the RACA score).ResultsCPR by the ALS unit was attempted in a total of 1989 patients (735, 666, and 588 patients in the first, second and third period, respectively). Average crude incidence of CPR per 100,000 person-years decreased over time (61.3; 55.5; 49.0/100,000/years) while patients treated were significantly older (65.5 ± 16.5; 67.9 ± 15; 68.9 ± 15.7 (p < 0.001)). Observed ROSC rates were higher than predicted by the RACA score in all time periods, however, admittance to ICU decreased significantly from 50% in the first five-year period to 38% last five-year period (p < 0.001). From first to third period the proportion of arrests with first observed rhythm of VT/VF arrests did not change (29% vs. 27%, p = 0.323) nor there were changes in bystander CPR rates (17% vs. 17%, p = 0.520).ConclusionsIn a 15-years period and in the setting of a physician-staffed EMS the ROSC rates remain higher than predicted by the RACA score but the admittance to the ICU after OHCA declined significantly. This finding was accompanied by a decrease in CPR incidence and an increase in age of patients.     

The combined use of mechanical CPR and a carry sheet to maintain quality resuscitation in out-of-hospital cardiac arrest patients during extrication and transport

BackgroundQuality of manual cardiopulmonary resuscitation (CPR) during extrication and transport of out-of-hospital cardiac arrest victims is known to be poor. Performing manual CPR during ambulance transport poses significant risk to the attending emergency medical services crew. We sought to use pre-hospital video recording to objectively analyse the impact of introducing mechanical CPR with an extrication sheet (Autopulse, Zoll) to an advanced, second-tier cardiac arrest response team.MethodsThe study was conducted prospectively using defibrillator downloads and analysis of pre-hospital video recording to measure the quality of CPR during extrication from scene and ambulance transport of the OHCA patient. Adult patients with non-traumatic OHCA were included. The interruption to manual CPR to during extrication and to deploy the mechanical CPR device was analysed.ResultsIn the manual CPR group, 53 OHCA cases were analysed for quality of CPR during extrication. The median time that chest compression was interrupted to allow the patient to be carried from scene to the ambulance was 270 s (IQR 201–387 s). 119 mechanical CPR cases were analysed. The median time interruption from last manual compression to first Autopulse compression was 39 s (IQR 29–47 s). The range from last manual compression to first Autopulse compression was 14–118 s.ConclusionMechanical CPR used in combination with an extrication sheet can be effectively used to improve the quality of resuscitation during extrication and ambulance transport of the refractory OHCA patient. The time interval to deploy the mechanical CPR device can be shortened with regular simulation training.     

Recurrent ventricular fibrillation: Experience with first responders prior to advanced life support interventions

AimFollowing defibrillation, ventricular fibrillation (VF) frequently recurs during out-of-hospital cardiac arrest (OHCA). Prior studies have reported conflicting results regarding its association with survival. The aim of this study was to examine the impact of recurrent VF in the presence of first responders before advanced life support (ALS) interventions.MethodsElectrocardiographic data from first responder automated external defibrillators (AEDs) were analyzed. A successful shock was defined as termination of VF for 5 s or longer. Recurrent VF was defined as any VF that occurred after a successful shock. The primary outcome was neurologically intact survival to hospital discharge (CPC 1–2).Results108 patients within our emergency system experienced a witnessed VF arrest. Of these, 73 (68%) had at least one recurrence of VF. Median time to recurrence of VF was 25 s [interquartile range (IQR) 11–66 s]. Median time in recurrent VF was 180 s (IQR 105–266 s). Survival was observed in 25 (71%) of patients with no recurrent VF and in 36 (49%) who had recurrence. Recurrent VF was associated with a lower odds of survival on univariate analysis (OR 0.39, 95% CI 0.16–0.92, p = 0.0325). After adjusting for bystander CPR, gender and age, recurrent VF had a similar direction of effect but was no longer significantly associated with neurologically intact survival (OR 0.44, 95% CI 0.17–1.11, p = 0.081).ConclusionsIn the presence of first responders, VF recurred in 68% of patients. Recurrent VF was associated with a lower odds of survival, though its prognostic significance appeared to be blunted when considered in light of confounding variables. Recurrent VF may have significant survival implications, and further studies to assess its prognostic significance should be performed.     

Interventional strategies associated with improvements in survival for out-of-hospital cardiac arrests in Singapore over 10 years

AimWe aim to study if there has been an improvement in survival for Out-of-Hospital Cardiac Arrest (OHCA) in Singapore, the effects of various interventional strategies over the past 10 years, and identify strategies that contributed to improved survival.MethodsRates of OHCA survival were compared between 2001–2004 and 2010–2012, using nationwide data for all OHCA presenting to EMS and public hospitals. A multivariate logistic regression model for survival to discharge was constructed to identify strategies with significant impact.ResultsA total of 5453 cases were included, 2428 cases from 2001 to 2004 and 3025 cases from 2010 to 2012. There was significant improvement in Utstein (witnessed, shockable) survival to discharge from 2001–2004 (2.5%) to 2010–2012 (11.0%), adjusted odds ratio (OR) 9.6 [95% CI: 2.2–41.9]). Overall survival to discharge increased from 1.6% to 3.2% (adjusted OR 2.2 [1.5–3.3]). Bystander CPR rates increased from 19.7% to 22.4% (p = 0.02). The multivariate regression model (adjusted for important non-modifiable risk factors) showed that response time <8 min (OR 1.5 [1.0–2.3]), bystander AED (OR 5.8 [2.0–16.2]), and post-resuscitation hypothermia (OR 30.0 [11.5–78.0]) were significantly associated with survival to hospital discharge. Conversely, pre-hospital epinephrine (OR 0.6 [0.4–0.9]) was associated negatively with survival.ConclusionsOHCA survival has improved in Singapore over the past 10 years. Improvement in response time, public AEDs and post-resuscitation hypothermia appear to have contributed to the increase in survival. Singapore's experience might suggest that developing EMS systems should focus on reducing times to basic life support, including bystander defibrillation and post-resuscitation care.     

Correlation between initial serum levels of lactate after return of spontaneous circulation and survival and neurological outcomes in patients who undergo therapeutic hypothermia after cardiac arrest

ObjectivesWe analysed the relationship between serum levels of lactate within 1 h of return of spontaneous circulation (ROSC) and survival and neurological outcomes in patients who underwent therapeutic hypothermia (TH).MethodsThis was a multi-centre retrospective and observational study that examined data from the first Korean Hypothermia Network (KORHN) registry from 2007 to 2012. The inclusion criteria were out-of-hospital cardiac arrest (OHCA) and examination of serum levels of lactate within 1 h after ROSC, taken from KORHN registry data. The primary endpoint was survival outcome at hospital discharge, and the secondary endpoint was poor neurological outcome (Cerebral Performance Category, CPC, 3–5) at hospital discharge. Initial lactate levels and other variables collected within 1 h of ROSC were analysed via multivariable logistic regression.ResultsData from 930 cardiac arrest patients who underwent TH were collected from the KORHN registry. In a total of 443 patients, serum levels of lactate were examined within 1 h of ROSC. In-hospital mortality was 289/443 (65.24%), and 347/443 (78.33%) of the patients had CPCs of 3–5 upon hospital discharge. The odds ratios of lactate levels for CPC and in-hospital mortality were 1.072 (95% confidence interval (CI) 1.026–1.121) and 1.087 (95% CI = 1.031–1.147), respectively, based on multivariate ordinal logistic regression analyses.ConclusionHigh levels of lactate in serum measured within 1 h of ROSC are associated with hospital mortality and high CPC scores in cardiac arrest patients treated with TH.     

Association of presence and timing of invasive airway placement with outcomes after pediatric in-hospital cardiac arrest

BackgroundLittle data exist regarding the association of presence of an invasive airway before cardiac arrest or early placement of an invasive airway after cardiac arrest with outcomes in children who experience in-hospital cardiac arrest.MethodsWe conducted a retrospective review of patients aged 1 day to 18 years who received cardiopulmonary resuscitation (CPR) for ≥1 min in any of the three intensive care units (ICUs) at a tertiary care, academic children's hospital between 2002 and 2010. Specific outcomes evaluated included survival to hospital discharge, return of spontaneous circulation (ROSC), 24-h survival, and good neurological status at hospital discharge. We fitted multivariable logistic regression models to evaluate the association between the presence of an invasive airway prior to cardiac arrest and timing of placement of an invasive airway with these outcomes.ResultsThree hundred and ninety-one patients were included. Of these, 197 (51%) patients were already tracheally intubated before the occurrence of cardiac arrest. Median time to intubation was 6 min [interquartile range (IQR): 2, 12] among the 194 patients tracheally intubated following cardiac arrest. We found lower survival to hospital discharge among patients intubated prior to cardiac arrest (intubated vs. non-intubated group, 43% vs. 61%, p < 0.001). After adjusting for patient and event characteristics, presence of an invasive airway prior to cardiac arrest was not associated with a significant improvement in survival to hospital discharge [odds ratio (OR): 0.70, 95% confidence interval (CI): 0.42–1.16, p = 0.17], or good neurological outcomes (OR: 0.60, 95% CI: 0.34–1.05, p = 0.07). Similarly, early placement of an invasive airway after cardiac arrest was also not associated with an improvement in survival to hospital discharge (OR: 1.05, 95% CI: 0.78–1.42, p = 0.73), or good neurological outcomes (OR: 1.08, 95% CI: 0.77–1.53, p = 0.65).ConclusionsOur study demonstrates that presence of an invasive airway prior to cardiac arrest or early placement of an invasive airway after cardiac arrest is not associated with an improvement in survival to hospital discharge or good neurological outcomes. Further study of the relationship between invasive airway management and survival following cardiac arrest is warranted.     

Cardiopulmonary resuscitation quality and patient survival outcome in cardiac arrest: A systematic review and meta-analysis

AimTo conduct a systematic review and meta-analysis to determine whether cardiopulmonary resuscitation (CPR) quality, as indicated by parameters such as chest compression depth, compression rate and compression fraction, is associated with patient survival from cardiac arrest.MethodsFive databases were searched (MEDLINE, Embase, CINAHL, Scopus and Cochrane) as well as the grey literature (MedNar). To satisfy inclusion criteria, studies had to document human cases of in- or out-of hospital cardiac arrest where CPR quality had been recorded using an automated device and linked to patient survival. Where indicated (I² < 75%), meta-analysis was undertaken to examine the relationship between individual CPR quality parameters and either survival to hospital discharge (STHD) or return of spontaneous circulation (ROSC).ResultsDatabase searching yielded 8,842 unique citations, resulting in the inclusion of 22 relevant articles. Thirteen were included in the meta-analysis. Chest compression depth was significantly associated with STHD (mean difference (MD) between survivors and non-survivors 2.59 mm, 95% CI: 0.71, 4.47); and with ROSC (MD 0.99 mm, 95% CI: 0.04, 1.93). Within the range of approximately 100–120 compressions per minute (cpm), compression rate was significantly associated with STHD; survivors demonstrated a lower mean compression rate than non-survivors (MD −1.17 cpm, 95% CI: −2.21, −0.14). Compression fraction could not be examined by meta-analysis due to high heterogeneity, however a higher fraction appeared to be associated with survival in cases with a shockable initial rhythm.ConclusionsChest compression depth and rate were associated with survival outcomes. More studies with consistent reporting of data are required for other quality parameters.     

The duration of cardiopulmonary resuscitation in emergency departments after out-of-hospital cardiac arrest is associated with the outcome: A nationwide observational study

Aim of the studyThe appropriate duration of cardiopulmonary resuscitation (CPR) for patients who experience out-of-hospital cardiac arrest (OHCA) remains unknown. This study aimed to evaluate the duration of CPR in emergency departments (EDs) and to determine whether the institutions’ median duration of CPR was associated with survival-to-discharge rate.MethodsA cohort of adult patients from a nationwide OHCA registry was retrospectively evaluated. The main variable was the median duration of CPR for each ED (institutional duration), and the main outcome was survival to discharge. Multivariable logistic regression analysis was performed to adjust for individual and aggregated confounders.ResultsAmong the 107,736 patients who experienced OHCA between 2006 and 2010, 30,716 (28.5%) were selected for analysis. The median age was 65 years, and 67.1% were men. The median duration of CPR for all EDs was 28 min, ranging from 11 to 45 min. EDs were categorized into 3 groups according to their institutional duration of CPR: groups A (<20 min), B (20–29 min), C (≥30 min). The observed survival rates of the 3 groups were 2.11%, 5.20%, and 5.62%, respectively. Compared with group B, the adjusted difference (95% confidence interval) for survival to discharge was 3.01% (1.90–4.11, P < 0.001) for group A, and 0.33% (−0.64 to 1.30, P = 0.51) for group C.ConclusionThe duration of CPR varied widely among hospitals. The institutional duration of CPR less than 20 min was significantly associated with lower survival-to-discharge rate.     

Effect of implementation of new resuscitation guidelines on quality of cardiopulmonary resuscitation and survival

BackgroundDuring cardiopulmonary resuscitation (CPR), advanced life support (ALS) providers have been shown to deliver inadequate CPR with long intervals without chest compressions. Several changes made to the 2005 CPR Guidelines were intended to reduce unnecessary interruptions. We have evaluated if quality of CPR performed by the Oslo Emergency Medical System (EMS) improved after implementation of the modified 2005 CPR Guidelines, and if any such improvement would result in increased survival.Materials and methodsRetrospective, observational study of all consecutive adult cardiac arrest patients treated during a 2-year period before (May 2003–April 2005), and after (January 2006–December 2007) implementation of the modified 2005 CPR Guidelines. CPR quality was assessed from continuous electronic recordings from LIFEPACK 12 defibrillators where ventilations and chest compressions were identified from transthoracic impedance changes. Ambulance run sheets, Utstein forms and hospital records were collected and outcome evaluated.ResultsResuscitation was attempted in 435 patients before and 481 patients after implementation of the modified 2005 CPR Guidelines. ECGs usable for CPR quality evaluation were obtained in 64% and 76% of the cases, respectively. Pre-shock pauses decreased from median (interquartile range) 17 s (11, 22) to 5 s (2, 17) (p = 0.000), overall hands-off ratios from 0.23 ± 0.13 to 0.14 ± 0.09 (p = 0.000), compression rates from 120 ± 9 to 115 ± 10 (p = 0.000) and ventilation rates from 12 ± 4 to 10 ± 4 (p = 0.000). Overall survival to hospital discharge was 11% and 13% (p = 0.287), respectively.ConclusionQuality of CPR improved after implementation of the modified 2005 Guidelines with only a weak trend towards improved survival to hospital discharge.     

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

BackgroundRecommended for decades, the therapeutic value of adrenaline (epinephrine) in the resuscitation of patients with out-of-hospital cardiac arrest (OHCA) is controversial.PurposeTo investigate the possible time-dependent outcomes associated with adrenaline administration by Emergency Medical Services personnel (EMS).MethodsA retrospective analysis of prospectively collected data from a near statewide cardiac resuscitation database between 1 January 2005 and 30 November 2013. Multivariable logistic regression was used to analyze the effect of the time interval between EMS dispatch and the initial dose of adrenaline on survival. The primary endpoints were survival to hospital discharge and favourable neurologic outcome.ResultsData from 3469 patients with witnessed OHCA were analyzed. Their mean age was 66.3 years and 69% were male. An initially shockable rhythm was present in 41.8% of patients. Based on a multivariable logistic regression model with initial adrenaline administration time interval (AATI) from EMS dispatch as the covariate, survival was greatest when adrenaline was administered very early but decreased rapidly with increasing (AATI); odds ratio 0.94 (95% Confidence Interval (CI) 0.92–0.97). The AATI had no significant effect on good neurological outcome (OR = 0.96, 95% CI = 0.90–1.02).ConclusionsIn patients with OHCA, survival to hospital discharge was greater in those treated early with adrenaline by EMS especially in the subset of patients with a shockable rhythm. However survival rapidly decreased with increasing adrenaline administration time intervals (AATI).     

Out-of-hospital cardiac arrest survival improving over time: Results from the Resuscitation Outcomes Consortium (ROC)

BackgroundOut-of-hospital cardiac arrest (OHCA) remains a leading cause of death and a 2010 meta-analysis concluded that outcomes have not improved over several decades. However, guidelines have changed to emphasize CPR quality, minimization of interruptions, and standardized post-resuscitation care. We sought to evaluate whether OHCA outcomes have improved over time among agencies participating in the Resuscitation Outcomes Consortium (ROC) cardiac arrest registry (Epistry) and randomized clinical trials (RCTs).MethodsObservational cohort study of 47,148 EMS-treated OHCA cases in Epistry from 139 EMS agencies at 10 ROC sites that participated in at least one RCT between 1/1/2006 and 12/31/2010. We reviewed patient, scene, event characteristics, and outcomes of EMS-treated OHCA over time, including subgroups with initial rhythm of pulseless ventricular tachycardia or ventricular fibrillation (VT/VF).ResultsMean response interval, median age and male proportion remained similar over time. Unadjusted survival to discharge increased between 2006 and 2010 for treated OHCA (from 8.2% to 10.4%), as well as for subgroups of VT/VF (21.4% to 29.3%) and bystander witnessed VT/VF (23.5% to 30.3%). Compared with 2006, adjusted survival to discharge was significantly higher in 2010 for treated cases (OR = 1.72; 95% CI 1.53, 1.94), VT/VF cases (OR = 1.69; 95% CI 1.45, 1.98) and bystander witnessed VT/VF cases (OR = 1.65; 95% CI 1.36, 2.00). Tests for trend in each subgroup were significant (p < 0.001).ConclusionsROC-wide survival increased significantly between 2006 and 2010. Additional research efforts are warranted to identify specific factors associated with this improvement.     

Initial end-tidal carbon dioxide as a prognostic indicator for inpatient PEA arrest

AimInvestigate the relationship of initial PetCO2 values of patients during inpatient pulseless electrical activity (PEA) cardiopulmonary arrest with return of spontaneous circulation (ROSC) and survival to discharge.MethodsThis study was performed in two urban, academic inpatient hospitals. Patients were enrolled from July 2009 to July 2013. A comprehensive database of all inpatient resuscitative events is maintained at these institutions, including demographic, clinical, and outcomes data. Arrests are stratified by primary etiology of arrest using a priori criteria. Inpatients with PEA arrest for whom recorded PetCO2 was available were included in the analysis. Capnography data obtained after ROSC and/or more than 10 min after initiation of CPR were excluded. Multivariable logistic regression was used to explore the association between initial PetCO2 >20 mmHg and both ROSC and survival-to-discharge.ResultsA total of 50 patients with PEA arrest and pre-ROSC capnography were analyzed. CPR continued an average of 11.8 min after initial PetCO2 was recorded confirming absence of ROSC at time of measurement. Initial PetCO2 was higher in patients with versus without eventual ROSC (25.3 ± 14.4 mmHg versus 13.4 ± 6.9 mmHg, P = 0.003). After adjusting for age, gender, and arrest location (ICU versus non-ICU), initial PetCO2 >20 mmHg was associated with increased likelihood of ROSC (adjusted OR 4.8, 95% CI 1.2–19.2, P = 0.028). Initial PetCO2 was not significantly associated with survival-to-discharge (P = 0.251).ConclusionsInitial PetCO2 >20 mmHg during CPR was associated with ROSC but not survival-to-discharge among inpatient PEA arrest victims. This analysis is limited by relatively small sample size.     

Impact of time to return of spontaneous circulation on neuroprotective effect of targeted temperature management at 33 or 36 degrees in comatose survivors of out-of hospital cardiac arrest

AimTime to Return of Spontaneous Circulation (ROSC) has a plausible relation to severity of hypoxic injury before and during resuscitation in Out-of-Hospital Cardiac Arrest (OHCA), and has consistently been associated with adverse outcome. The effect of Targeted Temperature Management (TTM) may not be similar over the full spectrum of time to ROSC. This study investigated the possible beneficial effect of targeting 33 °C over 36 °C on the prognostic importance of time to ROSC.MethodsIn predefined sub-study of the TTM-trial (NEJM 2013) we investigated the relationship between time to ROSC, level of TTM and mortality and neurological outcome as assessed by the Cerebral Performance Category (CPC) scale and modified Rankin Scale (mRS) after 180 days.ResultsProlonged time to ROSC was significantly associated with increased mortality with a hazard ratio (HR) of 1.02 per minute (95% CI 1.01–1.02). Level of TTM did not modify the association of time to ROSC and mortality, p_interaction = 0.85. Prolonged time to ROSC was associated with reduced odds of surviving with a favorable neurological outcome for CPC (p = 0.008 for CPC 1–2) and mRS (p = 0.17, mRS 0–3) with no significant interaction with level of TTM.ConclusionTime to ROSC remains a significant prognostic factor in comatose OHCA patients with regards to risk of death and risk of adverse neurological outcome. For any time to ROSC, targeting 33 °C in TTM was not associated with benefit with regards to reducing mortality or risk of adverse neurological outcome compared to targeting 36 °C.     

Racial disparities in outcomes following PEA and asystole in-hospital cardiac arrests

AimTo define the racial differences present after PEA and asystolic IHCA and explore factors that could contribute to this disparity.MethodsWe analyzed PEA and asystolic IHCA in the Get-With-The-Guidelines-Resuscitation database. Multilevel conditional fixed effects logistic regression models were used to estimate the relationship between race and survival to discharge and return of spontaneous circulation (ROSC), sequentially controlling for hospital, patient demographics, comorbidities, arrest characteristic, process measures, and interventions in place at time of arrest.ResultsAmong the 561 hospitals, there were 76,835 patients who experienced IHCA with an initial rhythm of PEA or asystole (74.8% white, 25.2% black). Unadjusted ROSC rate was 55.1% for white patients and 54.1% for black patients (unadjusted OR: 0.94 [95% CI, 0.90–0.98], p = 0.016). Survival to discharge was 12.8% for white patients and 10.4% for black patients (unadjusted OR: 0.83 [95% CI, 0.78–0.87], p < 0.001). After adjusting for temporal trends, patient characteristics, hospital, and arrest characteristics, there remained a difference in survival to discharge (OR: 0.85 [95% CI, 0.79–0.92]) and rate of ROSC (OR: 0.88 [95% CI, 0.84–0.92]). Black patients had a worse mental status at discharge after survival. Rates of DNAR placed after survival from were lower in black patients with a rate of 38.3% compared to 44.5% in white patients (p < 0.001).ConclusionBlack patients are less likely to experience ROSC and survival to discharge after PEA or asystole IHCA. Individual patient characteristics, event characteristics, and hospital characteristics don’t fully explain this disparity. It is possible that disease burden and end-of-life preferences contribute to the racial disparity.     

Urban and rural differences in out-of-hospital cardiac arrest in Ireland

BackgroundMore than a third of Ireland's population lives in a rural area, defined as the population residing in all areas outside clusters of 1500 or more inhabitants. This presents a challenge for the provision of effective pre-hospital resuscitation services. In 2012, Ireland became one of three European countries with nationwide Out-of-Hospital Cardiac Arrest (OHCA) register coverage. An OHCA register provides an ability to monitor quality and equity of access to life-saving services in Irish communities.AimTo use the first year of national OHCAR data to assess differences in the occurrence, incidence and outcomes of OHCA where resuscitation is attempted and the incident is attended by statutory Emergency Medical Services between rural and urban settings.MethodsThe geographical coordinates of incident locations were identified and co-ordinates were then classified as ‘urban’ or ‘rural’ according to the Irish Central Statistics Office (CSO) definition.Results1798 OHCA incidents were recorded which were attended by statutory Emergency Medical Services (EMS) and where resuscitation was attempted. There was a higher percentage of male patients in rural settings (71% vs. 65%; p = 0.009) but the incidence of male patients did not differ significantly between urban and rural settings (26 vs. 25 males/100,000 population/year p = 0.353). A higher proportion of rural patients received bystander cardiopulmonary resuscitation (B-CPR) 70% vs. 55% (p ≤ 0.001), and had defibrillation attempted before statutory EMS arrival (7% vs. 4% (p = 0.019), respectively). Urban patients were more likely to receive a statutory EMS response in 8 min or less (33% vs. 9%; p ≤ 0.001). Urban patients were also more likely to be discharged alive from hospital (6% vs. 3%; p = 0.006) (incidence 2.5 vs. 1.1/100,000 population/year; p ≤ 0.001).Multivariable analysis of survival showed that the main variable of interest i.e. urban vs. rural setting was also independently associated with discharge from hospital alive (OR 3.23 (95% CI 1.43–7.31)).ConclusionThere are significant disparities in the incidence of resuscitation attempts in urban and rural areas. There are challenges in the provision of services and subsequent outcomes from OHCA that occur outside of urban areas requiring novel and innovative solutions. An integrated community response system is necessary to improve metrics around OHCA response and outcomes in rural areas.     

The impact of a pre-hospital critical care team on survival from out-of-hospital cardiac arrest

AimTo assess the impact of a pre-hospital critical care team (CCT) on survival from out-of-hospital cardiac arrest (OHCA).MethodsWe undertook a retrospective observational study, comparing OHCA patients attended by advanced life support (ALS) paramedics with OHCA patients attended by ALS paramedics and a CCT between April 2011 and April 2013 in a single ambulance service in Southwest England. We used multiple logistic regression to control for an anticipated imbalance of prognostic factors between the groups. The primary outcome was survival to hospital discharge. All data were collected independently of the research.Results1851 cases of OHCA were included in the analysis, of which 1686 received ALS paramedic treatment and 165 were attended by both ALS paramedics and a CCT. Unadjusted rates of survival to hospital discharge were significantly higher in the CCT group, compared to the ALS paramedic group (15.8% and 6.5%, respectively, p < 0.001). After adjustment using multiple logistic regression, the effect of CCT treatment was no longer statistically significant (OR 1.54, 95% CI 0.89–2.67, p = 0.13). Subgroup analysis of OHCA with first monitored rhythm of ventricular fibrillation or pulseless ventricular tachycardia showed similar results.ConclusionPre-hospital critical care for OHCA was not associated with significantly improved rates of survival to hospital discharge. These results are in keeping with previously published studies. Further research with a larger sample size is required to determine whether CCTs can improve outcome in OHCA.     

The effects of sodium bicarbonate during prolonged cardiopulmonary resuscitation

BackgroundThis study was performed to determine the effects of sodium bicarbonate injection during prolonged cardiopulmonary resuscitation (for > 15 minutes).MethodsThe retrospective cohort study consisted of adult patients who presented to the emergency department (ED) with the diagnosis of cardiac arrest in 2009. Data were retrieved from the institutional database.ResultsA total of 92 patients were enrolled in the study. Patients were divided into 2 groups based on whether they were treated (group1, n = 30) or not treated (group 2, n = 62) with sodium bicarbonate. There were no significant differences in demographic characteristics between groups. The median time interval between the administration of CPR and sodium bicarbonate injection was 36.0 minutes (IQR: 30.5-41.8 minutes). The median amount of bicarbonate injection was 100.2 mEq (IQR: 66.8-104.4). Patients who received a sodium bicarbonate injection during prolonged CPR had a higher percentage of return of spontaneous circulation, but not statistical significant (ROSC, 40.0% vs. 32.3%; P = .465). Sustained ROSC was achieved by 2 (6.7%) patients in the sodium bicarbonate treatment group, with no survival to discharge. No significant differences in vital signs after ROSC were detected between the 2 groups (heart rate, P = .124; systolic blood pressure, P = .094). Sodium bicarbonate injection during prolonged CPR was not associated with ROSC after adjust for variables by regression analysis (Table 3; P = .615; odds ratio, 1.270; 95% confidence interval: 0.501-3.219)ConclusionsThe administration of sodium bicarbonate during prolonged CPR did not significantly improve the rate of ROSC in out-of-hospital cardiac arrest.     

Intra-arrest hypothermia: Both cold liquid ventilation with perfluorocarbons and cold intravenous saline rapidly achieve hypothermia,but only cold liquid ventilation improves resumption of spontaneous circulation

BackgroundRapid intra-arrest induction of hypothermia using total liquid ventilation (TLV) with cold perfluorocarbons improves resuscitation outcome from ventricular fibrillation (VF). Cold saline intravenous infusion during cardiopulmonary resuscitation (CPR) is a simpler method of inducing hypothermia. We compared these 2 methods of rapid hypothermia induction for cardiac resuscitation.MethodsThree groups of swine were studied: cold preoxygenated TLV (TLV, n = 8), cold intravenous saline infusion (S, n = 8), and control (C, n = 8). VF was electrically induced. Beginning at 8 min of VF, TLV and S animals received 3 min of cold TLV or rapid cold saline infusion. After 11 min of VF, all groups received standard air ventilation and closed chest massage. Defibrillation was attempted after 3 min of CPR (14 min of VF). The end point was resumption of spontaneous circulation (ROSC).ResultsPulmonary arterial (PA) temperature decreased after 1 min of CPR from 37.2 °C to 32.2 °C in S and from 37.1 °C to 34.8 °C in TLV (S or TLV vs. C p < 0.0001). Coronary perfusion pressure (CPP) was higher in TLV than S animals during the initial 3 min of CPR. Arterial pO₂ was higher in the preoxygenated TLV animals. ROSC was achieved in 7 of 8 TLV, 2 of 8 S, and 1 of 8 C (TLV vs. C, p = 0.03).ConclusionsModerate hypothermia was achieved rapidly during VF and CPR using both cold saline infusion and cold TLV, but ROSC was higher than control only in cold TLV animals, probably due to better CPP and pO₂. The method by which hypothermia is achieved influences ROSC.