Factors associated with sustained return of spontaneous circulation in children after out-of-hospital cardiac arrest of noncardiac origin

Purpose

The study aimed to determine the factors predictive of sustained return of spontaneous circulation (ROSC) in children with out-of-hospital cardiac arrest (OHCA) of noncardiac origin.

Methods

Eighty children were included in this retrospective study. The variables that lead to sustained ROSC and those that do not lead to sustained ROSC were analyzed. Survival analyses, including chance of achieving sustained ROSC and sum duration of ROSC, were conducted according to the duration of in-hospital cardiopulmonary resuscitation (CPR).

Results

Etiologies of noncardiac OHCA differed significantly across different age groups (P < .001). Only 8.8% of children had initial arrest rhythms that were shockable. Predictors of sustained ROSC included the initial cardiac rhythm (P = .002), a shorter period between collapse and the first chest compression (P = .002), a shorter in-hospital CPR duration (P = .004), and prehospital CPR (P = .007). In children where ROSC was initially sustained, those with in-hospital CPR of more than 20 minutes, ROSC was sustained for less time (P < .001).

Conclusions

Few children with noncardiac OHCA present with shockable cardiac rhythms. Furthermore, long-term ROSC is difficult to maintain in children who receive in-hospital CPR for more than 20 minutes.     

Shock outcome is related to prior rhythm and duration of ventricular fibrillation

BACKGROUND: Several different ventricular fibrillation (VF) analysis features based on ECG have been reported for shock outcome prediction. In this study we investigated the influence of the time from VF onset to shock delivery (VF duration) and the rhythm before onset of VF, on the probability of return of spontaneous circulation (ROSC). We also analysed how these factors relate to the VF analysis feature median slope. METHODS: ECG recordings from 221 cardiac arrest patients from previously published prospective studies on the quality of CPR were used. VF duration and prior rhythm were determined when VF occurred during the episode. Median slope before each shock was calculated. RESULTS: The median VF duration was shorter in shocks producing ROSC, 24 seconds (s) versus 70s (P<0.001). VF duration shorter than 30s resulted in 27% ROSC versus 10% for those longer than 30s (OR=3.5 [95% CI: 2.2-5.4]). The prior rhythm influenced the probability of ROSC, with perfusing rhythm being superior, followed by PEA, asystole, and "poor" PEA (broad complexes and/or irregular/very slow rate), respectively. The probability of ROSC corresponded well with the average median slope value for each group, but the correlation between median slope and VF duration was very poor (r2=0.05). CONCLUSIONS: Based on our findings, detection of VF during ongoing chest compressions might be valuable because VF of short duration was associated with ROSC. Further, the rhythm before VF affects shock outcome with a perfusing rhythm giving the best prospect. The median slope can be used for shock outcome prediction, but not for determining VF duration. A combination could be beneficial and warrants further studies.     

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

Introduction

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

Methods

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

Results

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

Conclusion

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

A prospective study of outcome of in-patient paediatric cardiopulmonary arrest

BACKGROUND: Few prospective studies of the incidence and outcome of paediatric in-hospital cardiopulmonary arrest have been reported to enable quality assurance comparisons within and between institutions. METHODS: All cardiac and respiratory arrests and their management over a 41-month period in children not subject to palliative treatment or to a 'do not resuscitate' order were recorded and analysed using the Utstein template. RESULTS: Cardiac arrest occurred in a total of 111 of 104,780 admissions (1.06/1000) while respiratory arrest alone occurred in 36 (0.34/1000). Return of spontaneous circulation (ROSC) was achieved in 81 patients (73%) in cardiac arrest but only 40 (36%) were discharged from hospital and 38 (34%) survived for 1 year. The 1-year survival from respiratory arrest alone was 97%. Cardiac arrest was four times more common (89 versus 22) and approximately 90 times the incidence in the intensive care unit compared with wards but 1-year survival was similar (34% versus 36%). The initial heart rhythms were hypotensive-bradycardia in 73 (66%) with 38% survival; asystole in 17 (15%) with 12% survival; ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) in 10 (9%) with 40% survival; pulseless electrical activity (PEA) in 10 (9%) with 30% survival and SVT in 1 with survival. Secondary ventricular fibrillation occurred in 15 children given adrenaline (epinephrine) for treatment of asystole, hypotensive-bradycardia or PEA of whom 11 had received adrenaline in an initial dose of > 15 mcg/kg and 4 had < 15 mcg/kg (P = 0.0013). Eleven of 15 patients (73%) in secondary VF never achieved ROSC. CONCLUSIONS: In-patient paediatric cardiac arrest has a mediocre outcome with a better outlook if the initial rhythm is hypotensive-bradycardia, VF or pulsatile VT. Doses of adrenaline greater than 15 mcg/kg given for non-shockable rhythms may cause secondary VF which has a worse outcome than primary VF.     

Dynamics and state transitions during resuscitation in out-of-hospital cardiac arrest

BACKGROUND: The state or rhythm during resuscitation, i.e. ventricular fibrillation/tachycardia (VF/VT), asystole (ASY), pulseless electrical activity (PEA), or return of spontaneous circulation (ROSC) determines management. The state is unstable and will change either spontaneously (e.g. PEA-->ASY) or by intervention (e.g. VF-->ASY after DC shock); temporary ROSC may also occur. To gain insight into the dynamics of this process, we analyzed the state transitions over time using real-life data. METHODS: Detailed recordings from 304 episodes of attempted resuscitation from out-of-hospital cardiac arrests of presumed cardiac etiology were obtained from modified Heartstart 4000 defibrillators. State transitions were visualized and described, and analyzed in terms of a Markov probability model. RESULTS: The median number of state transitions was 5 (range 1-39), and more transitions were observed with VF than PEA or asystole as the initial rhythm. Of 105 patients (35%) who regained ROSC at some point during CPR, only 65 (21%) achieved sustained ROSC; suggesting an unrealized survival potential. A 3-min transition probability matrix was estimated: for example, a patient early in VF has a probability of 31% to be in ASY, 32% of still being in VF, 5% to have temporary ROSC, and 2% to have sustained ROSC after 3 min. CONCLUSION: The dynamics of resuscitation can be described in terms of state transitions and a Markov probability model. This framework enables prediction of short-term clinical development, supports informed decisions during CPR, and suggests a novel area for research.     

Paediatric traumatic out-of-hospital cardiac arrests in Melbourne, Australia

Introduction

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

Methods

The Victorian Ambulance Cardiac Arrest Registry (VACAR) was used to identify all trauma related cases of OHCA in patients aged less than 16 years of age. Cases were linked with their coronial findings.

Results

Between 2000 and 2009, EMS attended 33,722 OHCAs including 2187 adult traumatic OHCAs. There were 538 (1.6%) OHCAs in children less than 16 years of age of which n = 64 were due to trauma. The median age (IQR) of paediatric traumatic OHCA was 7 (4.5–13) years and 44 were male (69%). Bystander CPR was performed in 22 cases (34.4%). The first recorded rhythm by EMS was asystole seen in 42 (66%), PEA in 14 (22%) cases and VF in 2 cases (3%). Cardiac output was present in 7 (11%) cases who subsequently had an EMS witnessed OHCA. EMS attempted resuscitation in 35 (55%) patients of whom 7 (20%) achieved ROSC and were transported, and 1 (3%) survived to hospital discharge with severe neurological sequelae; 14(40%) were transported with CPR of whom none survived. Coronial cause of death was multiple injuries in 35%, head injury in 33%, head and neck injury in 10%, chest injuries in 10% and other causes (12%).

Conclusions

Traumatic aetiology of OHCA when compared to the incidence of adult traumatic OHCAs is uncommon. Resuscitation efforts are seldom effective and associated with poor neurological outcome.     

早期测定血清神经元特异性烯醇化酶水平对心跳呼吸骤停复苏后住院患儿转归以及神经学预后的预测作用

目的探讨早期检测血清神经元特异性烯醇化酶（NSE）水平对发生心跳呼吸骤停（CRA）住院患儿复苏后转归以及神经学预后的预测作用。方法选择2006年1月至2008年12月发生CRA的住院患儿,分为死亡组和存活组,对存活患儿随访6个月,分为神经学预后不良组和预后良好组。比较患儿年龄、性别、骤停类型、CPR时间、ROSC后Glasgow昏迷评分（CCS）、瞳孔对光反射恢复、需要镇静与否;在复苏后24～36h随机测定外周静脉血清NSE浓度,比较组间采样时间以及血清NSE水平。利用受试者工作特征（ROC）曲线,分别取NSE对复苏后死亡和6月时神经学不良预后诊断特异度（Sp）为100％、敏感度（se）最高的点为截断（cutt-off）值,并计算阳性预测值（PPV）、阴性预测值（NPV）和正确度。结果最终纳入病例87例,ROSC43例,存活出院19例,死亡24例;随访6月后,神经学预后不良12例,预后良好7例。死亡组与存活组以及神经学预后不良组与良好组间比较,CPR时间、GCS、瞳孔对光反射恢复、需要镇静与否以及NSE血清水平存在显著统计学差异（P均〈0．05）。NSE水平与CPR时间呈显著正相关（r=0．901,P=0．00）;与GCS呈显著负相关（r=-0．813,P=0．00）。NSE对复苏后ROSC患儿转归的ROC曲线下面积为0．846±0．065（95％CI：0．720-0．973,P=0．oo）,截断值为90．6ng／ml,Se、Sp、PPV、NPV、准确度分别为20．8％、100％、100％、50％、53．5％;NSE对神经学预后的ROC曲线下面积为0．929±0．072（95％CI：0．788—1．069,P=0．002）,截断值为50．7ng／ml,se、Sp、PPV、NPV、准确度分别为50％、100％、100％、53．8％、68．4％。结论ROSC后早期血清NSE水平对复苏后患儿转归和神经学预后有预测意义。     

Assessment of a three-phase model of out-of-hospital cardiac arrest in patients with ventricular fibrillation

AIM: Cardiac arrest with ventricular fibrillation (VF) has been divided into three phases in which phase-specific therapy may improve outcome. The aim of this study was to assess the relationship between call-to-shock time, bystander CPR (BCPR), and cardiac arrest outcomes. METHODS: In a retrospective analysis of prospectively-acquired data from witnessed VF out-of-hospital cardiac arrests (OHCA), patients were classified as phases 1, 2, or 3 based on call-to-shock time (<5, 5-8, and >8 min) and further stratified based on performance of BCPR. Groups were compared with regard to survival, neurological outcome, and restoration of spontaneous circulation (ROSC) with defibrillation only (no ALS interventions to achieve sustained ROSC). RESULTS: Survival, neurologically intact survival, and ROSC with defibrillation were different between phases 1 and 2 (p=0.014 and p=0.005, p<0.01) but not between phases 2 and 3. Patients were further classified as having received BCPR (N=111) or no BCPR (N=107). Neurologically intact survival with and without BCPR, respectively, was 61% versus 72% (phase 1), 44% versus 41% (phase 2), and 42% versus 29% (phase 3). ROSC with defibrillation only with and without BCPR, respectively, was 64% versus 56% (phase 1), 37.0% versus 29% (phase 2), and 33% versus 8% (phase 3). ROSC with defibrillation alone was statistically higher in univariate analysis in phase 3 with BCPR (p=0.033) but not in multivariate analysis (p=0.068). CONCLUSIONS: BCPR did not significantly improve survival in any phase of OHCA, though there was a trend toward increased neurologically intact survival and increased ROSC with defibrillation alone in phase 3.     

影响急诊科心肺复苏效果的多因素分析

目的 寻找影响急诊科心肺复苏(CPR)效果的独立因素.方法 对照选择深圳市72家网络医院2004年9月至2009年1月急诊科进行过CPR的1 376例心脏停搏(CA)患者的调查表,用EpiData软件建立数据库,用SPSS 13.0软件进行两分类Logistic回归分析.结果 影响急诊科CA患者自主循环恢复(ROSC)的多因素分析显示,心室纤颤(VF)患者较心脏静止患者ROSC可能性大,相对比值比(OR)=3.071,P=0.000,95%可信区间(95%CI)=2.019～4.670;无脉搏电活动(PEA)较心脏静止患者ROSC可能性大,OR=1.730,P=0.036,95%CI=1.036～2.890;电击是ROSC的保护因素,OR=1.574,P=0.015,95%CI=1.093～2.265;肾上腺素累积剂量≤4 mg患者ROSC可能性较≥5 mg患者大,OR=1.483,P=0.037,95%CI=1.024～2.147;CA绝对时间是ROSC危险因素,OR=0.961,P=0.000,95%CI=0.946～0.976.影响急诊科CA患者生存入院的多因素分析显示,VF患者生存可能性大于心脏静止患者,OR=2.013,P=0.002,95%CI=1.299～3.121;肾上腺素累积剂量≤4 mg患者生存可能性较≥5 mg患者大,OR=2.289,P=0.000,95%CI=1.487～3.524;CA绝对时间是急诊科患者生存入院的危险因素,OR=0.951,P=0.000,95%CI=0.933～0.969.结论 急诊科CA患者ROSC的独立影响因素有:CA时心律、CA绝对时间、电击、肾上腺素累积剂量.急诊科CA患者生存入院的独立影响因素有:CA绝对时间、肾上腺素累积剂量、CA时心律.     

体外心肺复苏启动前因素对患者预后的影响

目的:分析体外心肺复苏（extracorporeal cardiopulmonary resuscitation,ECPR）启动前因素对患者预后的影响,以探讨ECPR的干预时机和改进策略。方法:回顾性分析2018年7月至2021年4月在湖南师范大学附属第一医院（湖南省人民医院）行ECPR的29例患者。按患者是否存活出院分为生存组( n=13)及死亡组( n=16),分析两组常规心肺复苏（conventional cardiopulmonary resuscitation,CCPR）时间（开始心肺复苏到体外膜肺氧合运转的时间）、ECPR前初始心律、院外及院内心搏骤停的构成比、外院转运病例构成比。按CCPR时间分为≤45 min组、45~60 min组及>60 min组分别比较其出院存活率及持续自主循环恢复（sustained return of spontaneous circulation,ROSC）率。本院院内心搏骤停患者按心搏骤停（cardiac arrest,CA）发生地点分为本科室亚组和其他科室亚组,比较其存活率。 结果:29例患者总体生存率44.83%,体外膜肺氧合（extracorporeal membrane oxygenation,ECMO）平均辅助时长114（33.5,142.5） h,CCPR平均时长60（44.5,80） min。生存组ECMO辅助时间（140.15±44.80）h较死亡组长（ P=0.001）,生存组CCPR时间明显低于死亡组（ P=0.010）。初始心律为可除颤心律组生存率更高（ P=0.010）。OHCA较IHCA患者病死率高（ P=0.020）。外院转运病例病死率高于本院病例（ P=0.025）。CCPR时间≤45min、45~60 min、>60 min三组患者出院生存率依次递减（ P=0.001）,ROSC率依次递减（ P=0.001)。本院院内心搏骤停患者,CA发生地点在本科室（急诊医学科）组与其他科室组生存率差异无统计学意义（ P=0.54）。 结论:ECPR出院存活率高于国内外报道的CCPR存活率,ECPR对难治性心搏骤停是有效的。ECPR的预后跟CCPR时间、CA初始心律、CA发生地点明显相关,提高ECPR存活率需加强宣教及团队建设。     

Improving the rate of return of spontaneous circulation for out-of-hospital cardiac arrests with a formal, structured emergency resuscitation team

OBJECTIVE: To assess the impact of a formal, structured resuscitation team in the emergency department (ED) on the success rate of cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA) patients. METHODS: This is a "three-phase" (organized, transitional, and re-organized), prospective study in which medical records of all OHCA patients who needed resuscitation in the ED during the three 6-month periods were reviewed and data were coded in out-of-hospital Utstein style formats. An organized resuscitation team existed in the organized and re-organized phases but not in the transitional phase. The study population consisted of adult patients with non-traumatic cardiac arrest (>18 years of age). RESULTS: The rates of return of spontaneous circulation (ROSC) were 51.3% for the organized phase, 31.0% for the transitional phase, and 53.1% for the re-organized phase ( P=0.013 ). The rates of ROSC from pulseless electrical activity (PEA)/asystole were significantly higher in periods with organized and re-organized teams ( P=0.007 ). The rates of ROSC for the ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT) sub-groups were not significantly different in all three periods ( P=0.406 ). The chance of survival-to-discharge was 9.2% in the organized period, 11.2% in the transitional period, and 15.6% in the re-organized period ( P=0.496 ). The existence of a formal, structured emergency resuscitation team in the ED (odds ratio: 2.56, 95% confidence interval: 1.35-4.80) and witness at the scene (odds ratio: 2.45, 95% confidence interval: 1.34-4.45) were the only independent predictors of successful ROSC of OHCA patients by multiple logistic regression analysis. CONCLUSION: The establishment of a formal and structured emergency resuscitation team in the ED is associated with an increased rate of ROSC for OHCA patients.     

Continuous Quality Improvement Efforts Increase Survival with Favorable Neurologic Outcome after Out-of-hospital Cardiac Arrest

Objective: To assess system-wide implementation of specific therapies focused on perfusion during cardiopulmonary resuscitation (CPR) and cerebral recovery after Return of Spontaneous Circulation (ROSC). Methods: Before and after retrospective analysis of an out-of-hospital cardiac arrest database. Implementation trial in the urban/suburban community of Alameda County, California, USA, population 1.6 million, from November 2009–December 2012. Adult patients with non-traumatic out-of-hospital cardiac arrest (OHCA) who received CPR and/or defibrillation. The impedance threshold device was used throughout this study and there was an increased use of mechanical CPR (mCPR) and in-hospital therapeutic hypothermia (HTH). Results: Rates of ROSC, survival to hospital discharge and Cerebral Performance Category (CPC) scores were compared using univariate and multivariable analyses. A total of 2,926 adult non-traumatic patients with OHCA received CPR during the study period. From 2009–2011 to 2012, there was an increase in ROSC from 29.0% to 34.4% (p = 0.003) and a non-significant increase in hospital discharge from 10.2% to 12.0% (p = 0.16). There was a 76% relative increase in survival with favorable neurologic function between the two periods, as determined by CPC ≤ 2, from 4.5% to 7.9% (unadjusted OR = 1.80; CI = 1.31, 2.48; p < 0.001). After adjusting for witnessed arrest, bystander CPR, initial rhythm (VT/VF vs. others), placement of an advanced airway, EMS response time, drugs administered, and age, the OR was 1.61 (1.10, 2.36; p = 0.015). Using a stepwise multivariable logistic regression model, the independent predictors of CPC ≤ 2 were 2012 (vs. 2009–2011; p = 0.022), witnessed arrest (p < 0.001), initial rhythm VT/VF (p < 0.001), and advanced airway (inverse association p < 0.001). Additional analyses of the three prescribed therapies, separately and in combination, demonstrated that for those patients admitted to the hospital, mCPR with HTH had the biggest impact on survival to hospital discharge with CPC ≤ 2. Conclusions: Specific therapies within a system of care (mCPR, HTH), developed to enhance circulation during CPR and cerebral recovery after ROSC, significantly improved survival by 74% with favorable neurologic function following OHCA.     

Epidemiology and outcomes of out-of-hospital cardiac arrest in Rochester, New York

OBJECTIVE: To characterize out-of-hospital cardiac arrest (OHCA) and factors that affect survival in a medium sized city that uses system status management for dispatch. METHODS: A retrospective cohort study of all adult OHCA patients treated by EMS between 1998 and 2001 was conducted using Utstein definitions. The primary endpoint was 1-year survival. RESULTS: Of the 1177 patients who experienced OHCA during the study period, 539 (46%) met inclusion criteria. Age ranged from 18 to 98 years (median 67). The median call-response interval was 5 min (range 0-21), and 93% were 9 min or less. There was no significant difference in the median call-response intervals between call location zip (Post) codes (p=0.07). Twenty percent of experienced ROSC (95% CI 17-23), 7% survived more than 30 days (95% CI 5-9%), and 5% survived to 1 year (95% CI 3-7%). In bivariate analysis, first rhythm and bystander CPR affected survival to 1 year. There was no significant difference in survival between male (4%) and female (7%), black (4%) and white (6%), or witnessed (7%) and unwitnessed arrest (4%). Logistic regression identified younger age, CPR initiated by bystander (19%) or first responder (41%), and presenting rhythm of VF/VT (32%) as factors associated with survival to 1 year. CONCLUSIONS: This study finds a 5% survival to 1 year among OHCA patients in Rochester, NY. A presenting rhythm of VF/VT and bystander CPR were associated with increased survival.     

海南省多中心心肺复苏Utstien模式注册研究

目的 本研究以心肺复苏乌斯坦因(Utstein)评估模式评价海南省13家医院心搏骤停患者流行病学特征、心肺复苏结果及其影响因素。方法 在Utstein指南基础上设计“海南省心肺复苏Utstein注册登记表”,在2007年1月1日至2010年12月31日期间对海南省13家医院急诊科心搏骤停心肺复苏患者实施注册登记。通过方差分析等统计学方法,对心肺复苏患者实施前瞻性描述性研究。结果 1125例心搏骤停患者男性占73.8％,女性26.2％,年龄为(53.9±13.1)岁,既往病史以冠心病最为多见,其次为高血压病;自主循环恢复率为23.8％,成活出院为7.4％。自主循环恢复和成活出院的患者中发病l min内获得心肺复苏患者所占比例分别为41.8％和49.4％。院内心搏骤停(IHCA)患者和院外心搏骤停(OHCA)患者ROSC率分别为36.3％,11.6％,成活出院率分别为11.5％,3.3％。心室纤颤/无脉性室性心动过速患者188例(16.7％),其自主循环恢复率及成活出院率分别为58.0％,21.8％。心源性心搏骤停448例(39.8％);其中院内与院外心搏骤停患者自主循环恢复率分别为36.3％,11.6％,成活出院率分别为11.5％,3.3％。非心源性心搏骤停677例(60.2％)。三级医院和二级医院自主循环恢复率分别为69.8％和30.2％,成活出院率分别为7.4％和7.3％。结论 心搏骤停更常见于男性。慢性疾病在本组患者中普遍存在,其中以冠心病和高血压病最为多见。院内心搏骤停患者自主循环恢复和成活出院率均明显高于院外心搏骤停患者。心室纤颤/无脉室性心动过速患者心肺复苏自主循环恢复及成活出院率高于其他类型初始心律的患者。缩短心肺复苏启动时间有助于提高自主循环恢复率及成活出院率。     

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

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

Post-resuscitative clinical features in the first hour after achieving sustained ROSC predict the duration of survival in children with non-traumatic out-of-hospital cardiac arrest

Aim of the study

Although sustained return of spontaneous circulation (ROSC) can be initially established after resuscitation from non-traumatic out-of-hospital cardiac arrest (OHCA) in some children, many of the children lose spontaneous circulation during hospital stay and do not survive to discharge. The aim of this study was to determine the clinical features during the first hour after ROSC that may predict survival to hospital discharge.

Methods

We retrospectively evaluated the medical records of 228 children who presented to the emergency department without spontaneous circulation following non-traumatic OHCA during the period January 1996 to December 2008. Among these children, 80 achieved sustained ROSC for at least 20 min. The post-resuscitative clinical features during the first hour after achieving sustained ROSC that correlated with survival, median duration of survival, and death were analyzed.

Results

Among the 80 children who achieved sustained ROSC for at least 20 min, 28 survived to hospital discharge and 6 had good neurologic outcomes (PCPC scale = 1 or 2). Post-resuscitative clinical features associated with survival included sinus cardiac rhythm (p = 0.012), normal heart rate (p = 0.008), normal blood pressure (p < 0.001), urine output > 1 ml/kg/h (p = 0.002), normal skin color (p = 0.016), lack of cardiopulmonary resuscitation (CPR)-induced rib fracture (p = 0.044), initial Glasgow Coma Scale score > 7 (p < 0.001), and duration of in-hospital CPR ≤ 10 min (p < 0.001). Furthermore, these variables were also significantly associated with the duration of survival (all p < 0.05).

Conclusions

The most important predictors of survival to hospital discharge in children with OHCA who achieve sustained ROSC are a normal heart rate, normal blood pressure, and an initial urine output > 1 ml/kg/h.     

Survey of outcome of CPR in pediatric in-hospital cardiac arrest in a medical center in Taiwan

Purpose of the studyWhile the outcomes of cardiopulmonary resuscitation (CPR) for pediatric in-hospital cardiac arrest (IHCA) are reported for many regions, none is reported for Asian countries. We report the outcomes of CPR for pediatric IHCA in a tertiary medical center in Taiwan and also identify prognostic factors associated with poor outcome.MethodsData were retrieved retrospectively from 2000 to 2003 and prospectively from 2004 to 2006 from our web-based registry system. We evaluated patients younger than 18 years of age who had IHCA and received CPR. The primary outcome was survival to hospital discharge, and the secondary outcomes were sustained return of spontaneous circulation (ROSC), and favorable neurological outcomes as assessed by pediatric cerebral performance categories (PCPC).ResultsWe identified 316 patients and the overall hospital survival was 20.9% and 16.1% had favorable neurological outcomes. Sixty-four patients ever supported with ECMO. We further analyzed 252 patients who underwent conventional CPR only and most had cardiac disease (133/252, 52.8%). The second most common preexisting condition was hematologic or oncologic disease (43/252, 17.1%). Of the 252 patients, 153 (60.7%) achieved sustained ROSC, 50 (19.8%) survived to discharge, and 39 patients (15.5%) had favorable neurological outcomes. CPR during off-work hours resulted in inferior chances of reaching sustained ROSC. Multivariate analysis showed that long CPR duration, hematology/oncology patients, and pre-arrest vasoactive drug infusion were significantly associated with decreased hospital survival (p < 0.05).ConclusionsOutcomes of CPR for pediatric patients with IHCA in Taiwan were comparable to corresponding reports in Western countries, but more hematology/oncology patients were included. Long CPR duration, hematologic or oncologic underlying diseases, and vasoactive agent infusion prior IHCA were associated with poor outcomes. The concept of palliative care should be proposed to families of terminally ill cancer patients in order to avoid unnecessary patient suffering. Also, establishing a balanced duty system in the future might increase chances of sustained ROSC.     

Changing EMS dispatcher CPR instructions to 400 compressions before mouth-to-mouth improved bystander CPR rates

Background

To examine the impact of changing dispatcher CPR instructions (400 compressions: 2 breaths, followed by 100:2 ratio) on rates of bystander CPR and survival in adults with presumed cardiac out-of-hospital arrest (OHCA) in Melbourne, Australia.

Methods

The Victorian Ambulance Cardiac Arrest Registry (VACAR) was searched for OHCA where Emergency Medical Services (EMS) attempted CPR between August 2006 and August 2009. OHCA included were: (1) patients aged ≥18 years old; (2) presumed cardiac etiology; and (3) not witnessed by EMS.

Results

For the pre- and post-study periods, 1021 and 2101 OHCAs met inclusion criteria, respectively. Rates of bystander CPR increased overall (45-55%, p < 0.001) and by initial rhythm (shockable 55-70%, p < 0.001 and non-shockable 40-46%, p = 0.01). In VF/VT OHCA, there were improvements in the number of patients arriving at hospital with a return of spontaneous circulation (ROSC) (48-56%, p = 0.02) and in survival to hospital discharge (21-29%, p = 0.002), with improved outcomes restricted to patients receiving bystander CPR. After adjusting for factors associated with survival, the period of time following the change in CPR instructions was a significant predictor of survival to hospital discharge in VF/VT patients (OR 1.57, 95% CI: 1.15-2.20, p = 0.005).

Conclusion

Following changes to dispatcher CPR instructions, significant increases were seen in rates of bystander CPR and improvements were seen in survival in VF/VT patients who received bystander CPR, after adjusting for factors associated with survival.     

U NDERSTANDING 12-L EAD EKG S : A P RACTICAL A PPROACH

Abstract

Background. Return of spontaneous circulation (ROSC) occurs in 35.0 to 61.0% of emergency medical services (EMS)-treated out-of-hospital cardiac arrests (OHCAs); however, not all patients achieving ROSC survive to hospital arrival or discharge. Previous studies have estimated the incidence of some types of rearrest(RA) at 61.0 to 79.0%, and the electrocardiogram (ECG) waveform characteristics of prehospital RA rhythms have not been previously described. Objectives. We sought to determine the incidence of RA in OHCA, to classify RA events by type, and to measure the time from ROSC to RA. We also conducted a preliminary analysis of the relationship between first EMS-detected rhythms and RA, as well as the effect of RA on survival. Methods. The Pittsburgh Regional Clinical Center of the National Heart, Lung, and Blood Institute (NHLBI) -sponsored Resuscitation Outcomes Consortium (ROC) provided cases from a population-based cardiac arrest surveillance program, ROC Epistry. Only OHCA cases of nontraumatic etiology with available and adequate ECG files were included. We analyzed defibrillator–monitor ECG tracings (Philips MRX), patient care reports (PCRs), and defibrillator audio recordings from EMS-treated cases of OHCA spanning the period from October 2006 to December 2008. We identified ROSC and RA through interpretation of ECG tracings and audio recordings. Rearrest events were categorized as ventricular fibrillation (VF), pulseless ventricular tachycardia (VT), asystole, and pulseless electrical activity (PEA) based on ECG waveform characteristics. Proportions of RA rhythms were stratified by first EMS rhythm and compared using Pearson's chi-square test. Logistic regression was used to test the predictive relationship between RA and survival to hospital discharge. Results. Return of spontaneous circulation occurred in 329 of 1,199 patients (27.4% [95.0% confidence interval (CI): 25.0–30.0%]) treated for cardiac arrest. Of these, 113 had ECG tracings that were available and adequate for analysis. Rearrest occurred in 41 patients (36.0% [95.0% CI: 26.0–46.0%]), with a total of 69 RA events. Survival to hospital discharge in RA cases was 23.1% (95.0% CI: 11.1–39.3%), compared with 27.8% (95.0% CI: 17.9–39.6%) in cases without RA. Counts of RA events by type were as follows: 17 VF (24.6% [95% CI: 15.2–36.5%]), 20 pulseless VT (29.0% [95.0% CI: 18.7–41.2%]), 26 PEA (37.0% [95.0% CI: 26.3–50.2%]), and six asystole (8.8% [95.0% CI: 3.3–18.0%]). Rearrest was not predictive of survival to hospital discharge; however, initial EMS rhythm was predictive of RA shockability. The overall median (interquartile range) time from ROSC to RA among all events was 3.1 (1.6–6.3) minutes. Conclusion. In this sample, the incidence of RA was 38.0%. The most common type of RA was PEA. Shockability of first EMS rhythm was found to predict subsequent RA rhythm shockability.