Aspects on the increase in bystander CPR in Sweden and its association with outcome

Aim

To describe changes in the proportion of bystanders performing cardiopulmonary resuscitation (CPR) in out of hospital cardiac arrest (OHCA) in Sweden and to study the impact of bystander CPR on ventricular fibrillation and on survival during various times.

Patients and methods

All patients who suffered from OHCA in Sweden in whom CPR was attempted and who were included in the Swedish cardiac arrest register (SCAR) between 1992 and 2005. Crew witnessed cases were excluded.

Results

In all 34,125 patients were included in the survey. Among witnessed OHCA the proportion of patients receiving bystander CPR increased from 40% in 1992 to 55% in 2005 (p < 0.0001). In non-witnessed OHCA the corresponding proportion increased from 22% to 44% (p < 0.0001). There was a significant increase in bystander CPR regardless of age, sex and place. The increase was only found when CPR was performed by lay persons (21% in 1992 to 40% in 2005; p < 0.0001). Bystander CPR was associated with an increased proportion of patients found in a shockable rhythm and a lower number of shocks to receive return of spontaneous circulation. Bystander CPR was associated with a similar increase in survival early and late in the evaluation.

Conclusion

There was a marked increase in bystander CPR in OHCA, when performed by lay persons, during the last 14 years in Sweden. Bystander CPR was associated with positive effects both on ventricular fibrillation and survival.     

New treatment bundles improve survival in out-of-hospital cardiac arrest patients: A historical comparison

Introduction

Before the introduction of the new international cardiac arrest treatment guidelines in 2005, patients with out-of-hospital cardiac arrest (OHCA) of cardiac origin in Northern Italy had very poor prognosis. Since 2006, a new bundle of care comprising use of automated external defibrillators (AEDs) and therapeutic hypothermia (TH) was started, while extracorporeal CPR program (ECPR) for selected refractory CA and dispatcher-assisted cardio-pulmonary resuscitation (CPR) was started in January 2010.

Objectives

We hypothesized that a program of bundled care might improve outcome of OHCA patients.

Methods

We analyzed data collected in the OHCA registry of the MB area between September 2007 and August 2011 and compared this with data from 2000 to 2003.

Results

Between 2007 and 2011, 1128 OHCAs occurred in the MB area, 745 received CPR and 461 of these had a CA of presumed cardiac origin. Of these, 125 (27%) achieved sustained ROSC, 60 (13%) survived to 1 month, of whom 51 (11%) were discharged from hospital with a good neurological outcome (CPC ≤ 2), and 9 with a poor neurological outcome (CPC > 2).Compared with data from the 2000 to 2003 periods, survival increased from 5.6% to 13.01% (p < 0.0001). In the 2007–2011 group, low-flow time and bystander CPR were independent markers of survival.

Conclusions

OHCA survival has improved in our region. An increased bystander CPR rate associated with dispatcher-assisted CPR was the most significant cause of increased survival, but duration of CA remains critical for patient outcome.     

Comparison of Medical Priority Dispatch (MPD) and Criteria Based Dispatch (CBD) relating to cardiac arrest calls

Background

Prompt emergency medical service (EMS) system activation with rapid delivery of pre-hospital treatment is essential for patients suffering out-of-hospital cardiac arrest (OHCA). The two most commonly used dispatch tools are Medical Priority Dispatch (MPD) and Criteria Based Dispatch (CBD). We compared cardiac arrest call processing using these two dispatch tools in two different dispatch centres.

Methods

Observational study of adult EMS confirmed (non-EMS witnessed) OHCA calls during one year in Richmond, USA (MPD) and Oslo, Norway (CBD). Patients receiving CPR prior to call, interrupted calls or calls where the caller did not have access to the patients were excluded from analysis. Dispatch logs, ambulance records and digitalized dispatcher and caller voice recordings were compared.

Results

The MPDS-site processed 182 cardiac arrest calls and the CBD-site 232, of which 100 and 140 calls met the inclusion criteria, respectively. The recognition of cardiac arrest was not different in the MPD and CBD systems; 82% vs. 77% (p = 0.42), and pre-EMS arrival CPR instructions were offered to 81% vs. 74% (p = 0.22) of callers, respectively. Time to ambulance dispatch was median (95% confidence interval) 15 (13, 17) vs. 33 (29, 36) seconds (p < 0.001) and time to chest compression delivery; 4.3 (3.7, 4.9) vs. 3.7 (3.0, 4.1) min for the MPD and CBD systems, respectively (p = 0.05).

Conclusion

Pre-arrival CPR instructions were offered faster and more frequently in the CBD system, but in both systems chest compressions were delayed 3–4 min. Earlier recognition of cardiac arrest and improved CPR instructions may facilitate earlier lay rescuer CPR.     

Prodromal symptoms of out-of-hospital cardiac arrests: A report from a large-scale population-based cohort study

Objective

Little is known about which symptoms are manifested before out-of-hospital cardiac arrest (OHCA). The objective of this study is to describe the prodromal symptoms of OHCA focusing on the onset of the symptom in relation of etiology of cardiac arrests, and to analyze the association between those symptoms and their outcomes after OHCA.

Methods

This prospective, population-based cohort study enrolled all persons aged 18 years or older who had experienced OHCA of presumed cardiac and non-cardiac origin that were witnessed by bystanders or emergency medical system (EMS) personnel in Osaka from 2003 through 2004.

Results

There were 1042 were presumed to be of cardiac origin and 424 of non-cardiac. Patients with non-cardiac origin were more likely to have prodromal symptoms than those with cardiac etiology (70.0% vs. 61.8%, p = 0.003). Over 40% of OHCA regardless of etiology had displayed symptoms at least several minutes before their arrest (40.2% [259/644] in those of cardiac origin and 45.5% [135/297] in those of non-cardiac origin). As to cardiac origin, the most frequent prodromal symptom was dyspnea (27.6%), followed by chest pain (20.7%) and syncope (12.7%). For non-cardiac origin, the most frequent symptom was also dyspnea (40.7%), but chest pain was rarely presented (3.4%). Although, prodromal symptoms themselves were not associated with better neurological outcomes (adjusted odds ratio [AOR], 2.03; 95% confidence interval [CI], 1.00–4.13), earlier contact to a patient yielded better neurological outcomes (AOR per every one-minute increase, 0.90; 95% CI, 0.82–0.99).

Conclusions

Many of OHCA regardless of etiology have prodromal symptoms before arrest. Prodromal symptoms induced early activation of the EMS system, and may thus improve outcomes after OHCA.     

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.     

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.     

Dispatcher-assisted bystander cardiopulmonary resuscitation in a metropolitan city: A before–after population-based study

Background

The goal of this study was to determine the effects of dispatcher-assisted bystander cardiopulmonary resuscitation (DA-CPR) on outcomes of out-of-hospital cardiac arrest (OHCA).

Methods

All EMS in a metropolitan city with a population of 10 million are dispatched by a single, centralized, and physician-supervised center. Data on patients with adult OHCA with cardiac etiology were collected from the dispatch center registry and from EMS run sheets and hospital medical record review from 2009 to 2011. A standardized DA-CPR protocol (aligned with the 2010 AHA guidelines) we implemented as an intervention in January 2011. The end points were survival to discharge, good neurological outcome, and bystander CPR rate. Multivariate logistic analysis was used to compare between intervention group (2011) and historical control group (2009–2010).

Results

Of 8.144 eligible patients, bystander CPR was performed for the patients in 5.7% (148/2600) of cases in 2009, 6.7% (190/2857) in 2010, and 12.4% (334/2686) in 2011 (p < 0.001). The survival to discharge rates was 7.1% (2009), 7.1% (2010), and 9.4% (2011) (p = 0.001). Good neurological outcomes occurred in 2.1% (2009), 2.0% (2010), and 3.6% (2011) of cases (p < 0.001). The adjusted ORs (95% CIs) for survival to discharge compared with 2009 were 1.33 (1.07–1.66) in 2011 and 1.12 (0.89–1.41) in 2010. The adjusted ORs (95% CIs) for good neurological outcomes were 1.67 (1.13–2.45) in 2011 and 1.13 (0.74–1.72) in 2010.

Conclusions

An EMS intervention using the DA-CPR protocol was associated with a significant increase in bystander CPR and an improved survival and neurologic outcome after OHCA.     

Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device

Background

A recent out-of-hospital cardiac arrest (OHCA) clinical trial showed improved survival to hospital discharge (HD) with favorable neurologic function for patients with cardiac arrest of cardiac origin treated with active compression decompression cardiopulmonary resuscitation (CPR) plus an impedance threshold device (ACD + ICD) versus standard (S) CPR. The current analysis examined whether treatment with ACD + ITD is more effective than standard (S-CPR) for all cardiac arrests of non-traumatic origin, regardless of the etiology.

Methods

This is a secondary analysis of data from a randomized, prospective, multicenter, intention-to-treat, OHCA clinical trial. Adults with presumed non-traumatic cardiac arrest were enrolled and followed for one year post arrest. The primary endpoint was survival to hospital discharge (HD) with favorable neurologic function (Modified Rankin Scale score ≤ 3).

Results

Between October 2005 and July 2009, 2738 patients were enrolled (S-CPR = 1335; ACD + ITD = 1403). Survival to HD with favorable neurologic function was greater with ACD + ITD compared with S-CPR: 7.9% versus 5.7%, (OR 1.42, 95% CI 1.04, 1.95, p = 0.027). One-year survival was also greater: 7.9% versus 5.7%, (OR 1.43, 95% CI 1.04, 1.96, p = 0.026). Nearly all survivors in both groups had returned to their baseline neurological function by one year. Major adverse event rates were similar between groups.

Conclusions

Treatment of out-of-hospital non-traumatic cardiac arrest patients with ACD + ITD resulted in a significant increase in survival to hospital discharge with favorable neurological function when compared with S-CPR. A significant increase survival rates was observed up to one year after arrest in subjects treated with ACD + ITD, regardless of the etiology of the cardiac arrest.     

Are trained individuals more likely to perform bystander CPR? An observational study

Background

This study aimed to evaluate the association of cardiopulmonary resuscitation (CPR) training with bystander resuscitation performance and patient outcomes after out-of-hospital cardiac arrest (OHCA).

Methods

This was a prospective, population-based cohort study of all persons aged 18 years or older with OHCA of presumed intrinsic origin and their rescuers from January through December 2008 in Takatsuki, Osaka prefecture, Japan. Data on resuscitation of OHCA patients were obtained by emergency medical service (EMS) personnel in charge based on the Utstein style. Rescuers’ characteristics including experience of CPR training were obtained by EMS personnel interview on the scene. The primary outcome was the attempt of bystander CPR.

Results

Data were collected for 120 cases out of 170 OHCAs of intrinsic origin. Among the available cases, 60 (50.0%) had previous CPR training (trained rescuer group). The proportion of bystander CPR was significantly higher in the trained rescuer group than in the untrained rescuer group (75.0% and 43.3%; p = 0.001). Bystanders who had previous experience of CPR training were 3.40 times (95% confidence interval 1.31-8.85) more likely to perform CPR compared with those without previous CPR training. The number of patients with neurologically favorable one-month survival was too small to evaluate statistical difference between the groups (2 [3.3%] in the trained rescuer group versus 1 [1.7%] in the untrained rescuer group; p = 0.500).

Conclusions

People who had experienced CPR training had a greater tendency to perform bystander CPR than people without experience of CPR training. Further studies are needed to prove the effectiveness of CPR training on survival.     

The impact of partial resuscitation attempts on the reported outcomes of out-of-hospital cardiac arrest in Victoria,Australia: Implications for Utstein-style outcome reports

Background

Success rates from cardiopulmonary resuscitation (CPR) are often quantified by Utstein-style outcome reports in populations who receive an attempted resuscitation. In some cases, evidence of futility is ascertained after a partial resuscitation attempt has been administered, and these cases reduce the overall effectiveness of CPR. We examine the impact of partial resuscitation attempts on the reported outcomes of out-of-hospital cardiac arrest (OHCA) in Victoria, Australia.

Methods

Between 2002 and 2012, 34,849 adult OHCA cases of presumed cardiac aetiology were included from the Victorian Ambulance Cardiac Arrest Registry. Resuscitation attempts lasting ≤10 min in cases which died on scene were defined as a partial resuscitation. We used logistic regression to identify factors associated with a partial resuscitation attempt in the emergency medical service (EMS) treated population. Survival outcomes with and without partial resuscitations were compared across included years.

Results

The proportion of partial resuscitations in the overall EMS treated population increased significantly from 8.6% in 2002 to 18.8% in 2012 (p for trend < 0.001), and were largely supported by documented evidence of irreversible death. Partial resuscitations were independently associated with older age, female gender, initial non-shockable rhythm, prolonged downtime, and lower skill level of EMS personnel. Selectively excluding partial resuscitations increased event survival by 7.6% (95% CI 4.1–11.2%), and survival to hospital discharge increased by 3.1% (95% CI 0.5–5.7%) in 2012 (p < 0.001 for both).

Conclusion

In our EMS system, evidence of futility was often identified after the commencement of a partial resuscitation attempt. Excluding these events from OHCA outcome reports may better reflect the overall effectiveness of CPR.     

A 5-year experience with cardiopulmonary resuscitation using extracorporeal life support in non-postcardiotomy patients with cardiac arrest

Background

Cardiopulmonary resuscitation (CPR) using extracorporeal life support (ECLS) system has been successfully used to support patients with in- and out-of-hospital cardiac arrest (IHCA, OHCA) when conventional measures have failed. The purpose of the current study is to report on our experience with extracorporeal CPR in non-postcardiotomy patients.

Methods

We retrospectively analysed a total of 85 consecutive adult patients, who have been treated with ECLS between January 2007 and January 2012.

Results

The mean CPR duration was 40 min (20–70 min). The mean ECLS support duration was 49 h (12–92 h). Twenty-eight patients (33%) had ECLS related complications. Forty patients (47%) were successfully weaned and 29 patients (34%) survived to hospital discharge. Among survivors, 93% were without severe neurologic deficit. Duration of CPR was shorter for survivors than for non-survivors [(25: 20–50 min) vs. (50: 25–86 min); p = 0.003]. Immediately after ECLS start, the mean blood lactate level was lower (p = 0.003), and the mean pH value was higher in the survivors’ group (p < 0.0001) compared to the non-survivors’ group. The CPR duration for the IHCA group (25: 20–50 min) was shorter compared to the OHCA group (70: 55–110 min; p < 0.0001). The survival rate in this group was higher compared to the OHCA group (42% vs. 15%; p < 0.02).

Conclusions

CPR using modern miniaturized ECLS systems should be established in the treatment of prolonged cardiac arrest and unsuccessful conventional CPR in selected patients. CPR with ECLS for OHCA has worse outcomes compared to IHCA. Duration of CPR was independent risk factor for mortality after extracorporeal CPR.     

Chest compression depth and survival in out-of-hospital cardiac arrest

Aim

Outcomes from out-of-hospital cardiac arrest (OHCA) may improve if rescuers perform chest compressions (CCs) deeper than the previous recommendation of 38–51 mm and consistent with the 2010 AHA Guideline recommendation of at least 51 mm. The aim of this study was to assess the relationship between CC depth and OHCA survival.

Methods

Prospective analysis of CC depth and outcomes in consecutive adult OHCA of presumed cardiac etiology from two EMS agencies participating in comprehensive CPR quality improvement initiatives. Analysis: Multivariable logistic regression to calculate adjusted odds ratios (aORs) for survival to hospital discharge and favorable functional outcome.

Results

Among 593 OHCAs, 136 patients (22.9%) achieved return of spontaneous circulation, 63 patients (10.6%) survived and 50 had favorable functional outcome (8.4%). Mean CC depth was 49.8 ± 11.0 mm and mean CC rate was 113.9 ± 18.1 CC min⁻¹. Mean depth was significantly deeper in survivors (53.6 mm, 95% CI: 50.5–56.7) than non-survivors (48.8 mm, 95% CI: 47.6–50.0). Each 5 mm increase in mean CC depth significantly increased the odds of survival and survival with favorable functional outcome: aORs were 1.29 (95% CI 1.00–1.65) and 1.30 (95% CI 1.00–1.70) respectively.

Conclusion

Deeper chest compressions were associated with improved survival and functional outcome following OHCA. Our results suggest that adhering to the 2010 AHA Guideline-recommended depth of at least 51 mm could improve outcomes for victims of OHCA.     

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.     

CPR variability during ground ambulance transport of patients in cardiac arrest

Aim of study

High-quality CPR is associated with improved outcomes from out-of-hospital cardiac arrest (OHCA). The purpose of this investigation was to compare the quality of CPR provided at the prehospital scene, during ambulance transport, and during the early minutes in the emergency department (ED).

Methods

A prospective observational review of consecutive adult patients with non-traumatic OHCA was conducted between September 2008 and February 2010. Patients with initiation of prehospital CPR were included as part of a statewide cardiac resuscitation quality improvement program. A monitor-defibrillator with accelerometer-based CPR measurement capability (E-series, ZOLL Medical) was utilized. CPR quality measures included variability in chest compression (CC) depth and rate, mean depth and rate, and the CC fraction. Variability of CC was defined as the mean of minute-to-minute standard deviation in CC depth or rate. CC fraction was defined as the percent of time that CPR was being performed when appropriate throughout resuscitation.

Results

Fifty-seven adult patients with OHCA had electronic CPR data recorded at the scene, in the ambulance, and upon arrival in the ED. Across time periods, there was increased variability in CC depth (scene: 0.20 in.; transport: 0.26 in.; ED: 0.31 in., P < 0.01) and rate (scene: 18.2 CC min⁻¹; transport: 26.1 CC min⁻¹; ED: 26.3 CC min⁻¹, P < 0.01). The mean CC depth, rate, and the CC fraction did not differ significantly between groups.

Conclusions

There was increased CC variability from the prehospital scene to the ED though there was no difference in mean CC depth, rate, or in CC fraction. The clinical significance of CC variability remains to be determined.     

Influence of nationwide policy on citizens’ awareness and willingness to perform bystander cardiopulmonary resuscitation

Aims

Public awareness to cardiopulmonary resuscitation (CPR) and cardiac arrest is influenced by systemic factors including related policies and legislations in the community. Here, we describe and compare the results of the two nationwide CPR surveys in 2007 and 2011 examining public awareness and attitudes to bystander CPR in South Korea along with changes in nationwide CPR policies and systemic factors.

Methods

This population-based study used specially designed questionnaires via telephone surveys. We conducted bi-temporal surveys by stratified cluster sampling to assess the impact of age, gender, and geographic regions in 2007 (n = 1029) and in 2011 (n = 1000). Logistic regression analysis was performed to identify factors associated with willingness to perform bystander CPR.

Results

Public awareness of automated external defibrillators increased from 3.0% in 2007 to 32.6% in 2011. The proportion of the population that underwent CPR training within the previous 2 years increased significantly from 26.9% to 49.0%. The factors most related with intention of bystander CPR were male gender, younger age, CPR awareness, recent CPR training, and qualified CPR learning. In 2011, 75.8% of respondents were more willing to perform bystander CPR for stranger vs. 68.3% in 2007 (p = 0.002). Additional dispatcher hands-only CPR increased this proportion (85.8%, p < 0.001). However, bystander CPR experience rates remained unchanged (3.6–3.9%).

Conclusion

Changes in nationwide CPR policies and systemic factors affected citizens’ awareness and willingness to perform bystander CPR. Additionally, applied dispatcher hands-only CPR and publicity increased public willingness to perform bystander CPR.     

Examining the contextual effects of neighborhood on out-of-hospital cardiac arrest and the provision of bystander cardiopulmonary resuscitation

Objective

To understand the association between neighborhood and individual characteristics in determining whether or not bystanders perform cardiopulmonary resuscitation (CPR) in cases of out-of-hospital cardiac arrest (OHCA).

Methods

Between October 1, 2005 to November 30, 2008, 1108 OHCA cases from Fulton County (Atlanta), GA, were eligible for bystander CPR. We conducted multi-level non-linear regression analysis and derived Empirical Bayes estimates for bystander CPR by census tract.

Results

279 (25%) cardiac arrest victims received bystander CPR. Provision of bystander CPR was significantly more common in witnessed events (odds ratio [OR] 1.64; 95% confidence interval [CI] 1.21-2.22, p < 0.001) and those that occurred in public locations (OR 1.67; 95% CI 1.16-2.40, p < 0.001). Other individual-level characteristics were not significantly associated with bystander CPR. Cardiac arrests in the census tracts that rank in the highest income quintile, as compared to the lowest income quintile were much more likely (OR 4.98; 95% CI 1.65-15.04) to receive bystander CPR.

Conclusion

Cardiac arrest victims in the highest income census tracts were much more likely to receive bystander CPR than in the lowest income census tracts, even after controlling for individual and arrest characteristics. Low-income neighborhoods may be particularly appropriate targets for community-based CPR training and awareness efforts.     

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.     

CPR-related injuries after manual or mechanical chest compressions with the LUCAS™ device: A multicentre study of victims after unsuccessful resuscitation

Aim

The reported incidence of injuries due to cardiopulmonary resuscitation using manual chest compressions (manual CPR) varies greatly. Our aim was to elucidate the incidence of CPR-related injuries by manual chest compressions compared to mechanical chest compressions with the LUCAS device (mechanical CPR) in non-survivors after out-of-hospital cardiac arrest.

Methods

In this prospective multicentre trial, including 222 patients (83 manual CPR/139 mechanical CPR), autopsies were conducted after unsuccessful CPR and the results were evaluated according to a specified protocol.

Results

Among the patients included, 75.9% in the manual CPR group and 91.4% in the mechanical CPR group (p = 0.002) displayed CPR-related injuries. Sternal fractures were present in 54.2% of the patients in the manual CPR group and in 58.3% in the mechanical CPR group (p = 0.56). Of the patients in the manual CPR group, there were 64.6% with at least one rib fracture versus 78.8% in the mechanical CPR group (p = 0.02). The median number of rib fractures among patients with rib fractures was 7 in the manual CPR group and 6 in the mechanical CPR group. No CPR-related injury was considered to be the cause of death.

Conclusion

In patients with unsuccessful CPR after out-of-hospital cardiac arrest, rib fractures were more frequent after mechanical CPR but there was no difference in the incidence of sternal fractures. No injury was deemed fatal by the pathologist.     

Implementation of the ALERT algorithm,a new dispatcher-assisted telephone cardiopulmonary resuscitation protocol,in non-Advanced Medical Priority Dispatch System (AMPDS) Emergency Medical Services centres

Objectives

Early bystander cardiopulmonary resuscitation (CPR) is a key factor in improving survival from out-of-hospital cardiac arrest (OHCA). The ALERT (Algorithme Liégeois d’Encadrement à la Réanimation par Téléphone) algorithm has the potential to help bystanders initiate CPR. This study evaluates the effectiveness of the implementation of this protocol in a non-Advanced Medical Priority Dispatch System area.

Methods

We designed a before and after study based on a 3-month retrospective assessment of victims of OHCA in 2009, before the implementation of the ALERT protocol in Liege emergency medical communication centre (EMCC), and the prospective evaluation of the same 3 months in 2011, immediately after the implementation.

Results

At the moment of the call, dispatchers were able to identify 233 OHCA in the first period and 235 in the second. Victims were predominantly male (59%, both periods), with mean ages of 64.1 and 63.9 years, respectively. In 2009, only 9.9% victims benefited from bystander CPR, this increased to 22.5% in 2011 (p < 0.0002). The main reasons for protocol under-utilisation were: assistance not offered by the dispatcher (42.3%), caller physically remote from the victim (20.6%). Median time from call to first compression, defined here as no flow time, was 253 s in 2009 and 168 s in 2011 (NS). Ten victims were admitted to hospital after ROSC in 2009 and 13 in 2011 (p = 0.09).

Conclusion

From the beginning and despite its under-utilisation, the ALERT protocol significantly improved the number of patients in whom bystander CPR was attempted.