Reduced in-hospital survival rates of out-of-hospital cardiac arrest victims with obstructive pulmonary disease

Aim

Out-of-hospital cardiac arrest (OHCA) due to sustained ventricular tachycardia/fibrillation (VT/VF) is common and often lethal. Patient's co-morbidities may determine survival after OHCA, and be instrumental in post-resuscitation care, but are poorly studied. We aimed to study whether patients with obstructive pulmonary disease (OPD) have a lower survival rate after OHCA than non-OPD patients.

Methods

We performed a community-based cohort study of 1172 patients with non-traumatic OHCA with ECG-documented VT/VF between 2005 and 2008. We compared survival to Emergency Room (ER), to hospital admission, to hospital discharge, and at 30 days after OHCA, of OPD-patients and non-OPD patients, using logistic regression analysis. We also compared 30-day survival of patients who were admitted to hospital, using multivariate logistic regression analysis.

Results

OPD patients (n = 178) and non-OPD patients (n = 994) had comparable survival to ER (75% vs. 78%, OR 0.9 [95% CI: 0.6–1.3]) and to hospital admission (56% vs. 57%, OR 1.0 [0.7–1.4]). However, survival to hospital discharge was significantly lower among OPD patients (21% vs. 33%, OR 0.6 [0.4–0.9]). Multivariate regression analysis among patients who were admitted to hospital (OPD: n = 100, no OPD: n = 561) revealed that OPD was an independent determinant of reduced 30-day survival rate (39% vs. 59%, adjusted OR 0.6 [0.4–1.0, p = 0.035]).

Conclusion

OPD-patients had lower survival rates after OHCA than non-OPD patients. Survival to ER and to hospital admission was not different between both groups. However, among OHCA victims who survived to hospital admission, OPD was an independent determinant of reduced 30-day survival rate.     

Resuscitation of patients suffering from sudden cardiac arrests in nursing homes is not futile

Background

Survival after out-of-hospital cardiac arrest (OHCA) has increased in recent years, and new data are therefore needed to avoid unsubstantiated statements when debating futility of resuscitation attempts following OHCA in nursing home (NH)-residents. We aimed to investigate the outcome and prognosis after OHCA in NH.

Methods

Consecutive Emergency Medical Service (EMS) attended OHCA-patients in Copenhagen during 2007–2011 were included. Utstein-criteria for pre-hospital data and review of individual patient charts for in-hospital post-resuscitation care were collected.

Results

A total of 2541 consecutive OHCA-patients were recorded, 245 (10%) of who were current NH-residents. NH-patients were older, more frequently female, had more witnessed arrests, fewer shockable primary rhythm and assumed cardiac aetiology, but shorter time to the return of spontaneous circulation (ROSC) compared to OHCA in non-nursing homes (non-NH). Overall 30-day survival rate was 9% in NH and 18% in non-NH, p < 0.001. Of the 245 NH-arrests 79 (32%) patients were admitted to hospital compared to 937 (41%) from non-NH (p < 0.001). Thirty-day survival rate in patients admitted to hospital were 27% for NH- and 42% for non-NH-patients, p < 0.001. OHCA in NH was, however, not associated with a significantly worse prognosis (HR = 0.88 (0.64–1.21), p = 0.4) after adjustment for known prognostic factors including co-morbidity.

Conclusions

Nursing home residents resuscitated from OHCA and admitted to hospital have similar survival rates as non-NH-patients when adjusting for known prognostic factors and pre-existing co-morbidity. A policy of not attempting resuscitation in nursing homes at all may therefore not be justified.     

Early antibiotics improve survival following out-of hospital cardiac arrest

Introduction

Therapeutic hypothermia (TH) has become standard management following out of hospital cardiac arrest (OHCA). Recent evidence suggests TH increases the incidence of pneumonia. We retrospectively assessed infective indicators after OHCA and evaluated the effect of antibiotics on survival.

Method

We identified all patients admitted to the ICU of a regional primary angioplasty hospital following OHCA from May 2007 to December 2010. We collected demographic and outcome data, evidence of infection and the use of antimicrobial therapy.

Results

138 patients were admitted to ICU following OHCA. The mortality rate was 68.1% with mean ICNARC predicted mortality of 77.5%. Of 138 patients, 135 (97.8%) had at least one positive marker of infection within 72 h.53 of 138 patients (38.4%) received antibiotics during the first 7 days of their ICU stay. The hospital mortality rate for these patients was significantly less than those not receiving antibiotics (56.6% vs. 75.3%; p = 0.025) with NNT of 5. Multivariate analysis demonstrated that antibiotic use was an independent predictor of survival.

Conclusion

The post-arrest management of OHCA is commonly complicated by infections, the accurate diagnosis of which is impaired by the associated increase in inflammatory markers, body temperature control, delay in the processing of samples and poor quality chest radiography.We have shown a significant reduction in mortality in patients who received antibiotics compared with patients who did not. This suggests that a formal clinical trial is warranted.     

Tertiary centres have improved survival compared to other hospitals in the Copenhagen area after out-of-hospital cardiac arrest

Aims

Out-of-hospital cardiac arrest (OHCA) has been reported to carry very varying morbidity and mortality. However, it remains unclear whether this is caused by intrinsic factors of the OHCA or due to the level of in-hospital care. The aim of this study is to compare 30-day and long-term mortality after OHCA at tertiary heart centres and non-tertiary university hospitals.

Methods and results

Data from the Copenhagen OHCA registry from June 2002 through December 2010 included a total of 1218 consecutive patients treated by the same mobile emergency care unit (MECU) with either return of spontaneous circulation (ROSC) or on-going resuscitation (n = 53) at hospital arrival. The MECU transported patients to the nearest hospital unless an ECG on scene suggested ST-segment elevation myocardial infarction, in which case patients were transported to the nearest tertiary centre for acute coronary angiography. Therefore, patients with ST-elevation myocardial infarction (n = 198) were excluded from the analysis. 30-day mortality was 56% vs. 76% and long term (up to 8 years) mortality was 78% vs. 94% for tertiary and non-tertiary hospitals, respectively, both p < 0.001. Multivariate analysis showed that admission to a non-tertiary hospital was independently associated with increased risk of death (HR = 1.32, 95% CI: 1.09–1.59, p = 0.004). Exclusion of patients with on-going resuscitation at admission resulted in HR = 1.34 (1.11–1.62), p = 0.003. A matched pair propensity score analysis of 255 patients confirmed the results of the proportional hazard analysis (HR = 1.35, 95% CI: 1.11–1.65 p = 0.003).

Conclusion

Admission to tertiary centres is associated with lower mortality rates after OHCA compared with non-tertiary hospitals.     

Lack of improved outcomes with increased use of targeted temperature management following out-of-hospital cardiac arrest: A multicenter retrospective cohort study

Study aims

To assess whether increased use of targeted temperature management (TTM) within an integrated healthcare delivery system resulted in improved rates of good neurologic outcome at hospital discharge (Cerebral Performance Category score of 1 or 2).

Methods

Retrospective cohort study of patients with OHCA admitted to 21 medical centers between January 2007 and December 2012. A standardized TTM protocol and educational program were introduced throughout the system in early 2009. Comatose patients eligible for treatment with TTM were included. Adjusted odds of good neurologic outcome at hospital discharge and survival to hospital discharge were assessed using multivariate logistic regression.

Results

A total of 1119 patients were admitted post-OHCA with coma, 59.1% (661 of 1119) of which were eligible for TTM. The percentage of patients treated with TTM markedly increased during the study period: 10.5% in the years preceding (2007–2008) vs. 85.1% in the years following (2011–2012) implementation of the practice improvement initiative. However, unadjusted in-hospital survival (37.3% vs. 39.0%, p = 0.77) and good neurologic outcome at hospital discharge (26.3% vs. 26.6%, p = 1.0) did not change. The adjusted odds of survival to hospital discharge (AOR 1.0, 95% CI 0.85–1.17) or a good neurologic outcome (AOR 0.94, 95% CI 0.79–1.11) were likewise non-significant.

Interpretation

Despite a marked increase in TTM rates across hospitals in an integrated delivery system, there was no appreciable change in the crude or adjusted odds of in-hospital survival or good neurologic outcomes at hospital discharge among eligible post-arrest patients.     

The impact of therapeutic hypothermia on neurological function and quality of life after cardiac arrest

Aims

To assess the impact of therapeutic hypothermia on cognitive function and quality of life in comatose survivors of out of Hospital Cardiac arrest (OHCA).

Methods

We prospectively studied comatose survivors of OHCA consecutively admitted in a 4-year period. Therapeutic hypothermia was implemented in the last 2-year period, intervention period (n = 79), and this group was compared to patients admitted the 2 previous years, control period (n = 77). We assessed Cerebral Performance Category (CPC), survival, Mini Mental State Examination (MMSE) and self-rated quality of life (SF-36) 6 months after OHCA in the subgroup with VF/VT as initial rhythm.

Results

CPC in patients alive at hospital discharge was significantly better in the intervention period with a CPC of 1–2 in 97% vs. 71% in the control period, p = 0.003, corresponding to an adjusted odds ratio of a favourable cerebral outcome of 17, p = 0.01. No significant differences were found in long-term survival (57% vs. 56% alive at 30 months), MMSE, or SF-36. Therapeutic hypothermia (hazard ratio: 0.15, p = 0.007) and bystander CPR (hazard ratio 0.19, p = 0.002) were significantly related to survival in the intervention period.

Conclusion

CPC at discharge from hospital was significantly improved following implementation of therapeutic hypothermia in comatose patients resuscitated from OCHA with VF/VT. However, significant improvement in survival, cognitive status or quality of life could not be detected at long-term follow-up.     

Myocardial infarction is a frequent cause of exercise-related resuscitated out-of-hospital cardiac arrest in a general non-athletic population

Background

Performing exercise is shown to prevent cardiovascular disease, but the risk of an out-of-hospital cardiac arrest (OHCA) is temporarily increased during strenuous activity. We examined the etiology and outcome after successfully resuscitated OHCA during exercise in a general non-athletic population.

Methods

Consecutive patients with OHCA were admitted with return of spontaneous circulation (ROSC) or on-going resuscitation at hospital arrival (2002–2011). Patient charts were reviewed for post-resuscitation data. Exercise was defined as moderate/vigorous physical activity.

Results

A total of 1393 OHCA-patients were included with 91(7%) arrests occurring during exercise. Exercise-related OHCA-patients were younger (60 ± 13 vs. 65 ± 15, p < 0.001) and predominantly male (96% vs. 69%, p < 0.001). The arrest was more frequently witnessed (94% vs. 86%, p = 0.02), bystander CPR was more often performed (88% vs. 54%, p < 0.001), time to ROSC was shorter (12 min (IQR: 5–19) vs. 15 (9–22), p = 0.007) and the primary rhythm was more frequently shock-able (91% vs. 49%, p < 0.001) compared to non-exercise patients. Cardiac etiology was the predominant cause of OHCA in both exercise and non-exercise patients (97% vs. 80%, p < 0.001) and acute coronary syndrome was more frequent among exercise patients (59% vs. 38%, p < 0.001). One-year mortality was 25% vs. 65% (p < 0.001), and exercise was even after adjustment associated with a significantly lower mortality (HR = 0.40 (95%CI: 0.23–0.72), p = 0.002).

Conclusions

OHCA occurring during exercise was associated with a significantly lower mortality in successfully resuscitated patients even after adjusting for confounding factors. Acute coronary syndrome was more common among exercise-related cardiac arrest patients.     

Prodromal symptoms and health care consumption prior to out-of-hospital cardiac arrest in patients without previously known ischaemic heart disease

Aims

To describe prodromal symptoms and health care consumption prior to an out-of-hospital cardiac arrest (OHCA) in patients without previously known ischaemic heart disease (IHD).

Background

The most common lethal event of cardiovascular disease is sudden cardiac death, and the majority occur outside hospital. Little is known about prodromal symptoms and health care consumption associated with OHCAs.

Design

Case-crossover study.

Methods

Medical records of 403 OHCA cases without previously known IHD, age 25–74 years in the MONICA myocardial registry in Norrbotten County 2000–2008, were reviewed. Presenting symptoms and emergency visits at public primary care facilities and internal medicine clinics in Norrbotten County were analyzed from the week prior to the OHCA and from the same week one year previously, which served as a control week. Unlike most studies we included unwitnessed arrests and those where no cardiopulmonary resuscitation (CPR) was attempted.

Results

Emergency visits were more common during the week prior to the OHCA than during the control week, both for visits to primary care (29 vs. 6, p < 0.001) and to internal medicine clinics (16 vs. 0, p < 0.001). Symptoms were more prevalent during the week prior to the OHCA (36.7 vs. 6.7%, p < 0.001). The most prevalent symptoms were chest pain (14.6 vs. 0%, p < 0.001), gastrointestinal symptoms (7.7 vs. 1.2%, p < 0.001) and dyspnoea/peripheral oedema (6.9 vs. 0.2%, p < 0.001).

Conclusions

Patients who suffer an OHCA seek health care and present prodromal symptoms significantly more often the week prior to the event than the same week one year earlier.     

Benefit of an early and systematic imaging procedure after cardiac arrest: Insights from the PROCAT (Parisian Region Out of Hospital Cardiac Arrest) registry

Aims

Identification of the cause of out-of-hospital cardiac arrest (OHCA) is of paramount importance. We investigated the ability of our imaging strategy to provide an early etiological diagnosis of OHCA and the influence of this strategy on ICU survival.

Methods

Retrospective review of a prospectively acquired ICU database (01/2000–12/2010) including all OHCA patients without obvious extracardiac cause, for which an early diagnosis research was conducted (coronary angiography and/or brain and chest CT scan) within 24 h after resuscitation. These procedures could be performed separately or be combined, according to a decision algorithm.

Results

Of the 1274 patients admitted after OHCA during this 10-year period, the imaging strategy was applied in 896 patients. Patients who benefited from coronary angiography and/or CT scan were admitted to our ICU after a median delay of 180 [130–220] min after resuscitation. Seven hundred and forty-five coronary angiographies were performed, of which 452 (61%) identified at least one significant coronary lesion deemed responsible for the OHCA. CT-scan was performed in 355 patients and provided a diagnosis in 72 patients (20%), mainly stroke (n = 38) and pulmonary embolism (n = 19). Overall, this strategy allowed early diagnosis in 524 patients (59%). ICU survival was significantly higher for patients with a diagnosis identified by coronary angiography as compared with CT-scan (43% vs 10%, p < 0.001).

Conclusion

The use of an early diagnosis protocol with immediate coronary angiography and/or CT scan provided the etiology of nearly two thirds of OHCA cases. In this large retrospective database, coronary angiography yielded a better diagnostic value than brain and/or chest CT-scan.     

Diurnal variations in incidence and outcome of out-of-hospital cardiac arrest including prior comorbidity and pharmacotherapy: A nationwide study in Denmark

Aim

To investigate diurnal variations in incidence and outcomes following out-of-hospital cardiac arrest (OHCA).

Methods

OHCA of presumed cardiac etiology were identified through the nationwide Danish Cardiac Arrest Registry (2001–2010). Time of day was divided into three time periods: daytime 07.00–14.59; evening 15.00–22.59; and nighttime 23.00–06.59.

Results

We identified 18,929 OHCA patients, aged ≥18 years. The median age was 72 years (IQR 62–80) and the majority were male (67.5%). OHCA occurrence varied across time periods, with 43.9%, 35.7% and 20.6% occurring during daytime, evening and nighttime, respectively. Nighttime patients were more likely to have: severe comorbidity (i.e. COPD), arrest in private home (87.2% vs. 69.0% and 73.0% daytime and evening, respectively), non-witnessed arrest (51.2% vs. 48.4% and 43.7%), no bystander CPR (75.9% vs. 68.4% and 66.1%), longer time interval from recognition of OHCA to rhythm analysis (12 min vs. 11 min and 11 min), and non-shockable heart rhythm (80.1% vs. 70.3% and 69.4%), all p < 0.0001. Nighttime patients were less likely to achieve return of spontaneous circulation on arrival at the hospital (7.5% vs. 14.8% and 15.1%) and 1-year survival (2.8% vs. 7.2% and 7.1%), p < 0.0001. Overall, the lower 1-year survival rate persisted after adjusting for patient-related and cardiac-arrest related characteristics mentioned above (OR 0.47, 95%CI 0.37–0.59; OR 0.51, 95%CI 0.40–0.65, compared to daytime and evening, respectively).

Conclusions

We found nighttime patients to have a lower survival compared to daytime and evening that persisted when adjusting for patient-related and cardiac-arrest related characteristics including comorbidities.     

Compressions during defibrillator charging shortens shock pause duration and improves chest compression fraction during shockable out of hospital cardiac arrest

Background

Previous studies have demonstrated significant relationships between shock pause duration and survival to hospital discharge from shockable out-of hospital (OHCA) cardiac arrest. Compressions during defibrillator charging (CDC) has been proposed as a technique to shorten shock pause duration.

Objective

We sought to determine the impact of CDC on shock pause duration and CPR quality measures in shockable OHCA.

Methods

We performed a retrospective review of all treated adult OHCA occurring over a 1 year period beginning August 1, 2011 after training EMS agencies in CDC. We included OHCA patients with an initial shockable rhythm, available CPR process data and shock pause data for up to the first three shocks of the resuscitation. CDC by EMS personnel was confirmed by review of impedance channel measures. We evaluated the relationship between CDC and shock pause duration as the primary outcome measure. Secondary outcome measures investigated the association between CDC and CPR quality measures.

Results

Among 747 treated OHCA 149 (23.4%) presented in a shockable rhythm of which 129 (81.6%) met study inclusion criteria. Seventy (54.2%) received CDC. There was no significant difference between the CDC and no CDC group with respect to Utstein variables. Median pre-shock pause (15.0 vs. 3.5 s; Δ 11.5; 95% CI: 6.81, 16.19), post-shock pause (4.0 vs. 3.0 s; Δ 1.0; 95% CI: −2.57, 4.57), and peri-shock pause (21.0 vs. 9.0 s; Δ 12.0; 95% CI: 5.03, 18.97) were all lower for those who received CDC. Mean chest compression fraction was significantly greater (0.77 vs. 0.70, Δ 0.07; 95% CI: 0.03, 0.11) with CDC. No significant difference was noted in compression rate or depth with CDC. Clinical outcomes did not differ between the two approaches (return of spontaneous circulation 62.7% vs. 62.9% p = 0.98, survival 25.4% vs. 27.1% p = 0.82), although the study was not powered to detect clinical outcome differences.

Conclusions

Compressions during defibrillator charging may shorten shock pause duration and improves chest compression fraction in shockable OHCA. Given the impact on shock pause duration, further study with a larger sample size is required to determine the impact of this technique on clinical outcomes from shockable OHCA.     

Increasing hospital volume is not associated with improved survival in out of hospital cardiac arrest of cardiac etiology

Background

Resuscitation centers may improve patient outcomes by achieving sufficient experience in post-resuscitation care. We analyzed the relationship between survival and hospital volume among patients suffering out-of-hospital cardiac arrest (OHCA).

Methods

This prospective cohort investigation collected data from the Cardiac Arrest Registry to Enhance Survival database from 10/1/05 to 12/31/09. Primary outcome was survival to discharge. Hospital characteristics were obtained via 2005 American Hospital Association Survey. A hospital's use of hypothermia was obtained via direct survey. To adjust for hospital- and patient-level variation, multilevel, hierarchical logistic regression was performed. Hospital volume was modeled as a categorical (OHCA/year ≤ 10, 11–39, ≥40) variable. A stratified analysis evaluating those with ventricular fibrillation or pulseless ventricular tachycardia (VF/VT) was also performed.

Results

The cohort included 4125 patients transported by EMS to 155 hospitals in 16 states. Overall survival to hospital discharge was 35% among those admitted to the hospital. Individual hospital rates of survival varied widely (0–100%). Unadjusted survival did not differ between the 3 hospital groups (36% for ≤10 OHCA/year, 35% for 11–39, and 36% for ≥40; p = 0.75). After multilevel adjustment, differences in survival across the groups were not statistically significant. Compared to patients at hospitals with ≤10 OHCA/year, adjusted OR for survival was 1.04 (CI₉₅ 0.83–1.28) among 11–39 annual volume and 0.97 (CI₉₅ 0.73–1.30) among the ≥40 volume hospitals. Among patients presenting with VF/VT, no difference in survival was identified between the hospital groups.

Conclusion

Survival varied substantially across hospitals. However, hospital OHCA volume was not associated with likelihood of survival. Additional efforts are required to determine what hospital characteristics might account for the variability observed in OHCA hospital outcomes.     

Predictors of long-term survival after out-of-hospital cardiac arrest: The impact of Activities of Daily Living and Cerebral Performance Category scores

Background

Current focus on immediate survival from out-of-hospital cardiac arrest (OHCA) has diverted attention away from the variables potentially affecting long-term survival.

Aim

To determine the relationship between neurological and functional status at hospital discharge and long-term survival after OHCA.

Methods

Prospective data collection for all OHCA patients aged >18 years in the Jerusalem district (n = 1043, 2008–2009). Primary outcome measure: Length of survival after OHCA. Potential predictors: Activities of Daily Living (ADL) and Cerebral Performance Category (CPC) scores at hospital discharge, age and sex.

Results

There were 52/279 (18.6%) survivors to hospital discharge. Fourteen were discharged on mechanical ventilation (27%). Interviews with survivors and/or their legal guardians were sought 2.8 ± 0.6 years post-arrest. Eighteen died before long-term follow-up (median survival 126 days, IQR 94–740). Six improved their ADL and CPC scores between discharge and follow-up. Long-term survival was positively related with lower CPC scores (p = 0.002) and less deterioration in ADL from before the arrest to hospital discharge (p = 0.001). For each point increment in ADL at hospital discharge, the hazard ratio of death was 1.31 (95%CI 1.12, 1.53, p = 0.001); this remained unchanged after adjustment for age and sex (HR 1.26, 95%CI 0.07, 1.48, p = 0.005).

Conclusions

One-third of the patients discharged from hospital after OHCA died within 30 months of the event. Long-term survival was associated both with better neurological and functional level at hospital discharge and a smaller decrease in functional limitation from before to after the arrest, yet some patients with a poor neurological outcome survived prolonged periods after hospital discharge.     

Esophageal temperature after out-of-hospital cardiac arrest: An observational study

Introduction

Out-of-hospital cardiac arrest (OHCA) is a significant cause of death and severe neurological disability. The only post-return of spontaneous circulation (ROSC) therapy shown to increase survival is mild therapeutic hypothermia (MTH). The relationship between esophageal temperature post OHCA and outcome is still poorly defined.

Methods

Prospective observational study of all OHCA patients admitted to a single centre for a 14-month period (1/08/2008 to 31/09/2009). Esophageal temperature was measured in the Emergency Department and Intensive Care Unit (ICU). Selected patients had pre-hospital temperature monitoring. Time taken to reach target temperature after ROSC was recorded, together with time to admission to the Emergency Department and ICU.

Results

164 OHCA patients were included in the study. 105 (64.0%) were pronounced dead in the Emergency Department. 59 (36.0%) were admitted to ICU for cooling; 40 (24.4%) died in ICU and 19 (11.6%) survived to hospital discharge. Patients who achieved ROSC and had esophageal temperature measured pre-hospital (n = 29) had a mean pre-hospital temperature of 33.9 °C (95% CI 33.2-34.5). All patients arriving in the ED post OHCA had a relatively low esophageal temperature (34.3 °C, 95% CI 34.1-34.6). Patients surviving to hospital discharge were warmer on admission to ICU than patients who died in hospital (35.7 °C vs 34.3 °C, p < 0.05). Patients surviving to hospital discharge also took longer to reach T_targ than non-survivors (2 h 48 min vs 1 h 32 min, p < 0.05).

Conclusions

Following OHCA all patients have esophageal temperatures below normal in the pre-hospital phase and on arrival in the Emergency Department. Patients who achieve ROSC following OHCA and survive to hospital discharge are warmer on arrival in ICU and take longer to reach target MTH temperatures compared to patients who die in hospital. The mechanisms of action underlying esophageal temperature and survival from OHCA remain unclear and further research is warranted to clarify this relationship.     

Chest compression-only cardiopulmonary resuscitation performed by lay rescuers for adult out-of-hospital cardiac arrest due to non-cardiac aetiologies

Objective

Bystander CPR improves survival in patients with out-of-hospital cardiac arrest (OHCA). For adult sudden collapse, bystander chest compression-only CPR (COCPR) is recommended in some circumstances by the American Heart Association and European Resuscitation Council. However, adults who arrest from non-cardiac causes may also receive COCPR. Because rescue breathing may be more important for individuals suffering OHCA secondary to non-cardiac causes, COCPR is not recommended for these cases. We evaluated the relationship of lay rescuer COCPR and survival after OHCA from non-cardiac causes.

Methods

Analysis of a statewide Utstein-style registry of adult OHCA, during a large scale campaign endorsing COCPR for OHCA from presumed cardiac cause. The relationship between lay rescuer CPR (both conventional CPR and COCPR) and survival to hospital discharge was evaluated.

Results

Presumed non-cardiac aetiologies of OHCA accounted for 15% of all cases, and lay rescuer CPR was provided in 29% of these cases. Survival to hospital discharge occurred in 3.8% after conventional CPR, 2.7% after COCPR, and 4.0% after no CPR (p = 0.85). The proportion of patients receiving COCPR was much lower in the cohort of OHCA from respiratory causes (8.3%) than for those with presumed cardiac OHCA (18.0%; p < 0.001).

Conclusions

In the setting of a campaign endorsing lay rescuer COCPR for cardiac OHCA, bystanders were less likely to perform COCPR on OHCA victims who might benefit from rescue breathing.     

Improved outcome of extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest – A comparison with that for extracorporeal rescue for in-hospital cardiac arrest

Purpose

The aim was to investigate the effects of extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA) and compare the results with those of in-hospital cardiac arrest (IHCA).

Methods

We analyzed our extracorporeal membrane oxygenation (ECMO) results for patients who received ECPR for OHCA or IHCA in the last 5 years. Pre-arrest, resuscitation, and post-resuscitative data were evaluated.

Results

In the last 5 years, ECPR was used 230 times for OHCA (n = 31) and IHCA (n = 199). The basic demographic data showed significant differences in age, cardiomyopathy, and location of the initial CPR. Duration of ischemia was shorter in the IHCA group (44.4 ± 24.7 min vs. 67.5 ± 30.6 min, p < 0.05). About 50% of each group underwent a further intervention to treat the underlying etiology. ECMO was maintained for a shorter duration in the OHCA patients (61 ± 48 h vs. 94 ± 122 h, p < 0.05). Survival to discharge was similar in the two groups (38.7% for OHCA vs. 31.2% for IHCA, p > 0.05), as was the favorable outcome rate (25.5% for OHCA vs. 25.1% for IHCA, p > 0.05). Survival was acceptable (about 33%) in both groups when the duration of ischemia was no longer than 75 min.

Conclusions

In addition to having a beneficial effect in IHCA, ECPR can lead to survival and a positive neurological outcome in selected OHCA patients after prolonged resuscitation. Our results suggest that further investigation of the use of ECMO in OHCA is warranted.     

Out-of-hospital cardiac arrest outcomes stratified by rhythm analysis

Background

Survival data for out-of-hospital cardiac arrest (OHCA) victims initially in PEA or asystole who convert to a shockable rhythm during attempted resuscitation, relative to an initial shockable rhythm, have never been previously reported. This study was done to assess OHCA outcomes among a large cohort of adults in the CARES dataset stratified by three rhythm categories: initial shockable (IS), converted shockable (CS), and never shockable (NS).

Methods

The study was IRB approved. All adult index events at participating sites (2005–2010) were study eligible. All patient data elements were provided. Odds ratios of CS and NS status for survival to hospital discharge were calculated via multivariate logistic regression that adjusted for demographics, site, resuscitation initiators, AED use, and other covariates.

Results

There were 40,274 OHCA records submitted to the CARES registry during the study period. After exclusions, our final sample size was 30,939 (7404 IS [23.9%], 3225 CS [10.4%], 20,310 NS [65.7%]). Raw survival rates of CS and NS patients were similar (4.7% vs. 4.1%, respectively; p = 0.08) but significantly lower than IS patients (26.9%; p < 0.001). The adjusted OR of survival to hospital discharge for CS was 0.17 (95%CI: 0.14, 0.20) and for NS it was 0.17 (95%CI: 0.15, 0.18) with IS as the referent.

Conclusion

After OHCA, the survival rate for CS victims is significantly lower than for IS patients. These findings suggest that CS and IS are different entities and that alternatives to existing resuscitation algorithm tailored to patients with CS should be investigated.     

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’.     

Predictive value of electrocardiogram in diagnosing acute coronary artery lesions among patients with out-of-hospital-cardiac-arrest

Aims

Acute coronary lesions are known to be the most common trigger of out of hospital cardiac arrest (OHCA). Aim of the present study was to assess the predictive value of ST-segment changes in diagnosing the presence of acute coronary lesions among OHCA patients

Methods

Findings of coronary angiography (CA) performed in patients resuscitated from OCHA were retrospectively reviewed and related to ST-segment changes on post-ROSC electrocardiogram (ECG)

Results

Ninety-one patients underwent CA after OHCA; 44% of patients had ST-segment elevation and 56% of patients had other ECG patterns on post-ROSC ECG. Significant coronary artery disease (CAD) was found in 86% of patients; CAD was observed in 98% of patients with ST-segment elevation and in 77% of patients with other ECG patterns on post-ROSC ECG (p = 0.004). Acute or presumed recent coronary artery lesions were diagnosed in 56% of patients, respectively in 85% of patients with ST-segment elevation and in 33% of patients with other ECG patterns (p < 0.001). ST-segment analysis on post-ROSC ECG has a good positive predictive value but a low negative predictive value in diagnosing the presence of acute or presumed recent coronary artery lesions (85% and 67%, respectively)

Conclusions

Electrocardiographic findings after OHCA should not be considered as strict selection criteria for performing emergent CA in patients resuscitated from OHCA without obvious extra-cardiac cause; even in the absence of ST-segment elevation on post-ROSC ECG, acute culprit coronary lesions may be present and considered the trigger of cardiac arrest     

Validity of reported data in the Swedish Cardiac Arrest Register in selected parts in Sweden

Aim

To describe differences and similarities between reported and non-reported data in the Swedish Cardiac Arrest Register in selected parts in Sweden.

Methods

Prospective and retrospective data for treated OHCA patients in Sweden, 2008–2010, were compared in the Swedish Cardiac Arrest Register. Data were investigated in three Swedish counties, which represented one third of the population. The recording models varied. Prospective data are those reported by the emergency medical service (EMS) crews, while retrospective data are those missed by the EMS crews but discovered afterwards by cross-checking with the local ambulance register.

Result

In 2008–2010, the number of prospectively (n = 2398) and retrospectively (n = 800) reported OHCA cases was n = 3198, which indicates a 25% missing rate.When comparing the two groups, the mean age was higher in patients who were reported retrospectively (69 years vs. 67 years; p = 0.003). There was no difference between groups with regard to gender, time of day and year of OHCA, witnessed status or initial rhythm. Bystander cardiopulmonary resuscitation (CPR) was more frequent among patients who were reported prospectively (65% vs. 60%; p = 0.023), whereas survival to one month was higher among patients who were reported retrospectively (9.2% vs. 11.9%; p = 0.035).

Conclusion

Among 3198 cases of OHCA in three counties in Sweden, 800 (25%) were not reported prospectively by the EMS crews but were discovered retrospectively as missing cases. Patients who were reported retrospectively differed from prospectively reported cases by being older, having less frequently received bystander CPR but having a higher survival rate. Our data suggest that reports on OHCA from national quality registers which are based on prospectively recorded data may be influenced by selection bias.