Impact of the number of on-scene emergency life-saving technicians and outcomes from out-of-hospital cardiac arrest in Osaka City

Backgrounds

In Japan, ambulance staffing for cardiac arrest responses consists of a 3-person unit with at least one emergency life-saving technician (ELST). Recently, the number of ELSTs on ambulances has increased since it is believed that this improves the quality of on-scene care leading to better outcomes from out-of-hospital cardiac arrest (OHCA). The objective of this study was to evaluate the association between the number of on-scene ELSTs and OHCA outcome.

Methods

This was a prospective cohort study of all bystander-witnessed OHCA patients aged ≥18 years in Osaka City from January 2005 to December 2007 using on an Utstein-style database. The primary outcome measure was one-month survival with favorable neurological outcome defined as a cerebral performance category ≤2. Multivariable logistic regression model were used to assess the contribution of the number of on-scene ELSTs to the outcome after adjusting for confounders.

Results

Of the 2408 bystander-witnessed OHCA patients, one ELST group was present in 639 (26.5%), two ELST were present in 1357 (56.4%), and three ELST group in 412 (17.1%). The three ELST group had a significantly higher rate of one-month survival with favorable neurological outcome compared with the one ELST group (8.0% versus 4.5%, adjusted OR 2.26, 95% CI 1.27–4.04), while the two ELST group did not (5.4% versus 4.5%, adjusted OR 1.34, 95% CI 0.82–2.19).

Conclusions

Compared with the one on-scene ELST group, the three on-scene ELST group was associated with the improved one-month survival with favorable neurological outcome from OHCA in Osaka City.     

Outcome when adrenaline (epinephrine) was actually given vs. not given - post hoc analysis of a randomized clinical trial

Purpose of the study

IV line insertion and drugs did not affect long-term survival in an out-of-hospital cardiac arrest (OHCA) randomized clinical trial (RCT). In a previous large registry study adrenaline was negatively associated with survival from OHCA. The present post hoc analysis on the RCT data compares outcomes for patients actually receiving adrenaline to those not receiving adrenaline.

Materials and methods

: Patients from a RCT performed May 2003 to April 2008 were included. Three patients from the original intention-to-treat analysis were excluded due to insufficient documentation of adrenaline administration. Quality of cardiopulmonary resuscitation (CPR) and clinical outcomes were compared.

Results

Clinical characteristics were similar and CPR quality comparable and within guideline recommendations for 367 patients receiving adrenaline and 481 patients not receiving adrenaline. Odds ratio (OR) for being admitted to hospital, being discharged from hospital and surviving with favourable neurological outcome for the adrenaline vs. no-adrenaline group was 2.5 (CI 1.9, 3.4), 0.5 (CI 0.3, 0.8) and 0.4 (CI 0.2, 0.7), respectively. Ventricular fibrillation, response interval, witnessed arrest, gender, age and endotracheal intubation were confounders in multivariate logistic regression analysis. OR for survival for adrenaline vs. no-adrenaline adjusted for confounders was 0.52 (95% CI: 0.29, 0.92).

Conclusion

Receiving adrenaline was associated with improved short-term survival, but decreased survival to hospital discharge and survival with favourable neurological outcome after OHCA. This post hoc survival analysis is in contrast to the previous intention-to-treat analysis of the same data, but agrees with previous non-randomized registry data. This shows limitations of non-randomized or non-intention-to-treat analyses.     

Out-of-hospital cardiac arrest due to drowning among children and adults from the Utstein Osaka Project

Background

Children have better outcomes after out-of-hospital cardiac arrest (OHCA) than adults. However, little is known about the difference in outcomes between children and adults after OHCA due to drowning.

Objectives

The aim of this study is to assess the outcome after OHCA due to drowning between children and adults. Our hypothesis is that outcomes after OHCA due to drowning would be in better among children (<18 years old) compared with adults (≥18 years old).

Method

This prospective population-based, observational study included all emergency medical service-treated OHCA due to drowning in Osaka, Japan, between 1999 and 2010 (excluding 2004). Outcomes were evaluated between younger children (0–4 years old), older children (5–17 years old), and adults (≥18 years old). Major outcome measures were one-month survival and neurologically favorable one-month survival defined as cerebral performance category 1 or 2. Multivariate logistic regression analyses were used to account for potential confounders.

Results

During the study period, 66,716 OHCAs were documented, and resuscitation was attempted for 62,048 patients (1300 children [2%] and 60,748 adults [98%]). Among these OHCAs, 1737 (3% of OHCAs) were due to drowning (36 younger children [2%], 32 older children [2%], and 1669 adults [96%]). The odds of one-month survival were significantly higher for younger children (28% [10/36]; adjusted odds ratio [AOR], 20.20 [95% confidence interval {CI} 7.45–54.78]) and older children (9% [3/32]; AOR, 4.47 [95% CI 1.04–19.27]) when compared with adults (2% [28/1669]). However, younger children (6% [2/36]; AOR, 5.23 [95% CI 0.52–51.73]) and older children (3% [1/32]; AOR, 2.53 [95% CI 0.19–34.07]) did not have a higher odds of neurologically favorable outcome than adults (1% [11/1669]).

Conclusion

In this large OHCA registry, children had better one-month survival rates after OHCA due to drowning compared with adults. Most survivors in all groups had unfavorable neurological outcomes.     

Prognostic implication of initial coagulopathy in out-of-hospital cardiac arrest

Objective

We sought to investigate the prognostic implication of early coagulopathy represented by initial DIC score in out-of-hospital cardiac arrest (OHCA).

Methods

OHCA registry was analyzed to identify patients with ROSC without recent use of anticoagulant between 2008 and 2011. Patients were assessed for prehosptial factors, initial laboratory results and therapeutic hypothermia. Outcome variables were survival discharge, 6-month CPC and survival duration within the first week after ROSC. Logistic regression and Cox proportional hazards models were used for both univariable and multivariable analysis.

Results

Among 273 eligible patients, initial DIC score was available in 252 (92.3%). Higher DIC score was associated with increased inhospital death (odds ratio [OR], 1.89 per unit; 95% confidence interval [CI], 1.48–2.41) and unfavorable long-term outcome (6-month CPC 3–5; OR, 2.21 per unit; 95% CI, 1.60–3.05). The adjusted ORs for both outcomes were 1.61 (95% CI, 1.17–2.22) and 1.84 (95% CI, 1.26–2.67), respectively. We categorized DIC score in five groups as <3, 3, 4, 5 and >5 and analyzed differential mortality risk using Cox proportional hazards model. Compared with reference group (DIC score < 3), the adjusted HR for early mortality in each remaining group was 1.96 (95% CI, 1.13–3.40), 2.26 (95% CI, 1.27–4.02), 2.77 (95% CI, 1.58–4.85) and 4.29 (95% CI, 2.22–8.30), respectively (p-trend < 0.001). The area under the receiver operating characteristic of DIC score for prediction of unfavorable long-term outcome was 0.79 (95% CI, 0.69–0.88).

Conclusion

Increased initial DIC score in OHCA was an independent predictor for poor outcomes and early mortality risk.     

Adult Out-of-Hospital Cardiac Arrest Based on Chain of Survival in Taoyuan County,Northern Taiwan

Background

Most out-of-hospital cardiac arrest (OHCA) studies have been conducted in developed countries or metropolitan areas, and few in developing countries or rural areas.

Objectives

The aims of this study were to determine the weak links in the chain of survival and to estimate the outcomes of OHCA patients in Taoyuan, a nonmetropolitan area in Taiwan.

Methods

A retrospective review and analysis of OHCA data was conducted. The three outcomes were whether a return of spontaneous circulation (ROSC) was achieved, whether the patient survived to admission, or whether the patient survived to hospital discharge.

Results

From April to December 2008, 1048 OHCA patients were resuscitated, and 712 (67.9%) adult cardiac patients were used in this study. Among these 712 patients, 17.8% achieved ROSC (95% confidence interval [CI] 15.2–20.8%), 16.3% survived to admission (95% CI 13.6–19.0%), and 1.4% survived to discharge (95% CI 0.5–2.3%). Factors significantly associated with the three outcomes were witness status, response time to emergency medical services, and whether the patient had a shockable rhythm. Bystander cardiopulmonary resuscitation (CPR) did not add a notable benefit to the outcomes of OHCA.

Conclusions

The survival rate of OHCA patients in nonmetropolitan Taiwan was very low (1.4%). Lower witnessed rate, lower bystander CPR rate, and longer response interval in remote areas are the main causes of inferior survival rate.     

Regional variability in survival outcomes of out-of-hospital cardiac arrest: The All-Japan Utstein Registry

Objective

There is a paucity of studies on the degree of regional variability in out-of-hospital cardiac arrest (OHCA) outcomes, particularly in neurological outcome. This study aimed to determine whether there is a significant regional variation in survival outcomes of OHCA across Japan.

Methods

We analyzed a prospective, nation-wide, population-based database (All-Japan Utstein Registry) involving all Japanese individuals who had non-traumatic OHCA resuscitated by emergency responders from January 2005 through December 2010. The primary study endpoint was favourable neurological survival at 1 month, defined as Cerebral Performance Category 1 or 2. We compared unadjusted and multivariable-adjusted rates of the outcome among seven geographic regions.

Results

In the total catchment population of 128 million, there were 539,641 non-traumatic OHCA patients. Unadjusted neurologically favourable survival varied across regions from 1.9% to 3.1% (rate difference, 1.2%; 95%CI, 1.0–1.3%); the Northeast region had a significantly lower rate compared to the Midwest region (unadjusted rate ratio, 0.62; 95%CI, 0.60–0.64). This disparity became larger after adjusting for patient- and prehospital-level confounders (adjusted rate ratio, 0.52; 95%CI, 0.51–0.54). Among 35,153 OHCA patients with return of spontaneous circulation, unadjusted neurologically favourable survival varied from 26.4% to 34.7% (rate difference, 8.3%; 95%CI, 6.6–10.1%); the East region had a significantly lower rate compared to the Midwest region (adjusted rate ratio, 0.72; 95%CI, 0.68–0.76).

Conclusion

In this prospective, nation-wide, population-based study in Japan, we found a two-fold regional difference in neurologically favourable survival after OHCA, suggesting regional disparities in prehospital care and in-hospital post-resuscitation care.     

Out-of-hospital cardiac arrest in patients treated with primary PCI for STEMI. Long-term follow up data from EUROTRANSFER registry

Objectives

Our aim was to describe long-term outcome of OHCA patients in a cohort of STEMI patients treated by primary PCI based on the EUROTRANSFER Registry data.

Background

The occurrence of cardiac arrest is associated with impaired survival. There are limited number of studies reporting outcome of STEMI patients with out-of-hospital cardiac arrest (OHCA) treated by primary percutaneous coronary intervention (PCI). The recently published resuscitation guidelines of the European Resuscitation Council (ERC) support immediate angiography/PCI or fibrinolysis in these patients in order to improve survival.

Methods

Consecutive data on 1650 STEMI patients, transferred for primary PCI in hospital STEMI networks between November 2005 and January 2007 from 7 countries in Europe were gathered. Patients were divided into two groups: OHCA group – 42 patients and no OHCA group – 1608 patients.

Results

Baseline demographics, clinical characteristic on admission to cathlab and past medical history were similar in both groups. Cardiogenic shock on admission or acute heart failure defined as Killip 3 + 4 was more frequently observed in OHCA group. The in-hospital mortality was similar, however, 1-year mortality was 19.1% in the OHCA group vs 8.1% in no OHCA group (p = 0.011) and remained significant after exclusion of patients in cardiogenic shock on admission.

Conclusions

STEMI patients treated with primary PCI with out-of-hospital cardiac arrest have higher long-term mortality than no OHCA patients. However, resuscitation prior to cathlab admission is not an independent predictor of long-term adverse outcome. No differences in in-hospital mortality were noticed.     

A comparison of outcomes of out-of-hospital cardiac arrest with non-cardiac etiology between emergency departments with low- and high-resuscitation case volume

Objectives

It is unclear whether outcome after out-of-hospital cardiac arrest (OHCA) of non-cardiac etiology (NCE) is associated with the volume of patients with OHCA received annually at the emergency department (ED) where they receive treatment. This study evaluated whether the volume of patients treated is associated with better outcomes for non-cardiac OHCA patients.

Methods

This study was performed in an emergency medical service (EMS) system with a single-tiered basic-to-intermediate service level and approximately 410 destination hospitals for eligible OHCA cases. A nationwide OHCA database (2006–2008), constructed from EMS run sheets, and a hospital medical record review were used. OHCA was defined as pulseless and unresponsive in the field. Included in the study were cases treated with OHCA whose etiology was non-cardiac. Excluded were cases with unknown hospital outcome. The cutoff number for a high volume (HV) versus a low volume (LV) of cardiopulmonary resuscitation (CPR) cases was calculated using a threshold model. The primary end points were survival to admission and survival to discharge. The adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs) for the endpoints were calculated, adjusting for potential predictors.

Results

There were 10,425 eligible patients (trauma 5735; drowning 98; poisoning 684; asphyxia 1413; and hanging 1605). The survival-to-admission and the survival-to-discharge rates of the study participants were 9.6% and 2.4%, respectively. The cutoff number for case volume was 38 per year. The rates of survival to admission and survival to discharge were significantly higher in the HV (18.6% and 5.1%, respectively) group when compared to the LV group (5.9% and 1.3%, respectively). For the treated, non-cardiac OHCA patients, the adjusted ORs in the HV group compared to the LV group were 2.16 for survival to admission (95% CI: 1.84–2.55) and 2.58 for survival to discharge (95% CI: 1.90–3.52). The survival-to-discharge rate was significantly higher in the HV group than in the LV group for each cause: trauma 2.1% vs. 0.6%, drowning 6.8% vs. 1.9%, poisoning 8.6% vs. 1.7%, asphyxia 13.5% vs. 3.8%, and hanging 5.2% vs. 1.3%, respectively.

Conclusion

This national cohort study suggests that greater survival to admission as well as discharge for patients with OHCA of NCE is associated with greater annual volume of patients with OHCA treated at that hospital.     

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.     

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.     

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.     

Direction of first bystander call for help is associated with outcome from out-of-hospital cardiac arrest

Background

Preventable bystander delays following out-of-hospital cardiac arrest (OHCA) are common, and include bystanders inappropriately directing their calls for help.

Methods

We retrospectively extracted Utstein-style data from the Victorian Ambulance Cardiac Arrest Registry (VACAR) for adult OHCA occurring in Victoria, Australia, between July 2002 and June 2012. Emergency medical service (EMS) witnessed events were excluded. Cases were assigned into two groups on the basis of the first bystander call for help being directed to EMS. Study outcomes were: likelihood of receiving EMS treatment; survival to hospital, and; survival to hospital discharge.

Results

A total of 44 499 adult OHCA cases attended by EMS were identified, of which first bystander calls for help were not directed to EMS in 2842 (6.4%) cases. Calls to a relative, friend or neighbour accounted for almost 60% of the total emergency call delays. Patient characteristics and survival outcomes were consistently less favourable when calls were directed to others. First bystander call to others was independently associated with older age, male gender, arrest in private location, and arrest in a rural region. The risk-adjusted odds of treatment by EMS (OR 1.33, 95% CI 1.20–1.48), survival to hospital (OR 1.64, 95% CI 1.37–1.96) and survival to hospital discharge (OR 1.64, 95% CI 1.13–2.36) were significantly improved if bystanders called EMS first.

Conclusion

The frequency of inappropriate bystander calls following OHCA was low, but associated with a reduced likelihood of treatment by EMS and poorer survival outcomes.     

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.     

The effect of percutaneous coronary intervention in patients suffering from ST-segment elevation myocardial infarction complicated by out-of-hospital cardiac arrest on 30 days survival

Aim of the study

To question the beneficial effects of the recommended early percutaneous coronary intervention (PCI) after out-of-hospital cardiac arrest on 30-day survival with favourable neurological outcome.

Methods

Prospectively collected data of 1277 out of hospital cardiac arrest patients between 2005 and 2010 from a registry at a tertiary care university hospital were used for a cohort study.

Results

In 494 (39%) arrest patients ST-segment elevation was identified in 249 (19%). Within 12 h after restoration of spontaneous circulation catheter laboratory investigations were initiated in 197 (79%) and PCI in 183 (93%) (78% got PCI in less than180 min). Adjustment for a cumulative time without chest compressions <2 min, initial shockable rhythm, cardiac arrest witnessed by healthcare professionals, and a higher core temperature at time of hospitalization reduced the effect of PCI on favourable neurological outcome at 30 days (OR 1.40; 95% CI, 0.53–3.7) compared to the univariate analysis (OR 2.52; 95% CI, 1.42–4.48).

Conclusion

This cohort study failed to demonstrate the beneficial effects of PCI as part of post-resuscitation care on 30-day survival with a favourable neurological outcome.     

Cardiocerebral resuscitation vs cardiopulmonary resuscitation for cardiac arrest: a systematic review

Objective

The objective of this study is to evaluate the efficacy of cardiocerebral resuscitation (CCR) vs cardiopulmonary resuscitation (CPR) for patients with out-of-hospital cardiac arrest (OHCA).

Methods

We conducted a systematic review of controlled trials and observational studies. We searched Cochrane Central Register of Controlled Trials; MEDLINE; Embase; and Chinese databases such as VIP, CNKI, WANFANG, and CBM from their inception to September 2010. Data from original studies were extracted and assessed with predefined criteria.

Results

Thirteen studies comprising 3 randomized controlled trials and 10 observational studies were included. Pooled analysis of 4 observational studies suggested that neurologically intact survival of patients with OHCA was improved in CCR group (odds ratio [OR], 1.45; 95% confidence interval [CI], 1.07-1.97). Survival to hospital discharge in the CCR group was superior or at least equal to that in CPR group (randomized controlled trial OR, 1.25; 95% CI, 1.01-1.55; cohort studies OR, 1.15; 95% CI, 0.72-1.82; case-control studies OR 0.85; 95% CI, 0.65-1.12). In the subgroup analysis of patients with a shockable rhythm as an initial rhythm, survival to hospital discharge was significantly improved in the CCR group (cohort studies OR, 2.03; 95% CI, 1.44-2.86). However, when only noncardiac origin cardiac arrest was taken into consideration, survival rate was better in the CPR group (cohort studies OR, 0.87; 95% CI, 0.77-0.98).

Conclusion

Cardiocerebral resuscitation might be equivalent or superior to CPR in patients with OHCA in both survival rate and neurologic benefits. Further work is needed to assess the efficacy of CCR for victims who had OHCA of noncardiac causes.     

Life support techniques related to survival after out-of-hospital cardiac arrest in infants

Aim of the study

The incidence rate of out-of-hospital cardiac arrest (OHCA) among infants is high; however, little is known about effective life-support for this group. Thus, we examined factors related to 1-month survival after OHCA among infants.

Methods

All infant OHCA cases occurring between 2005 and 2008 in Japan were extracted from the National Utstein Registry. Split-half random sampling and signal detection analysis were used to identify the effective factors on 1-month survival after OHCA.

Results

The mutual interaction of life support techniques and other factors were identified and used to divide the study population into five subgroups. A witness to the cardiac arrest, rescue breathing administered by a bystander, and less than 18 min to hospital arrival or a witness to the arrest, no rescue breathing and less than 7 min for the ambulance to arrive at the scene were found to be related to higher survival after OHCA in infants. The survival proportions for these subgroups were 44.83% (95% CI: 25.58–64.08) and 19.18% (95% CI: 14.64–23.72), respectively.

Conclusion

The probability of survival after OHCA in infants may be improved by a bystander witnessing the arrest and providing the rescue breathing at the first sight of arrest.     

Applicability of the prehospital termination of resuscitation rule in an area dense with hospitals in Tokyo: a single-center,retrospective, observational study : Is the pre hospital TOR rule applicable in Tokyo?

Background

It is unclear whether the prehospital termination of resuscitation (TOR) rule is applicable in specific situations such as in areas extremely dense with hospitals.

Objectives

The objective of the study is to assess whether the prehospital TOR rule is applicable in the emergency medical services system in Japan, specifically, in an area dense with hospitals in Tokyo.

Methods

This study was a retrospective, observational analysis of a cohort of adult out-of-hospital cardiopulmonary arrest (OHCA) patients who were transported to the University of Tokyo Hospital from April 1, 2009, to March 31, 2011.

Results

During the study period, 189 adult OHCA patients were enrolled. Of the 189 patients, 108 patients met the prehospital TOR rule. The outcomes were significantly worse in the prehospital TOR rule–positive group than in the prehospital TOR–negative group, with 0.9% vs 11.1% of patients, respectively, surviving until discharge (relative risk [RR], 1.11; 95% confidence interval [CI], 1.03-1.21; P = .0020) and 0.0% vs 7.4% of patients, respectively, discharged with a favorable neurologic outcome (RR, 1.08; 95% CI, 1.02-1.15; P = .0040). The prehospital TOR rule had a positive predictive value (PPV) of 99.1% (95% CI, 96.3-99.8) and a specificity of 90.0% (95% CI, 60.5-98.2) for death and a PPV of 100.0% (95% CI, 97.9-100.0) and a specificity of 100.0% (95% CI, 61.7-100.0) for an unfavorable neurologic outcome.

Conclusions

This study suggested that the prehospital TOR rule predicted unfavorable outcomes even in an area dense with hospitals in Tokyo and might be helpful for identifying the OHCA patients for whom resuscitation efforts would be fruitless.     

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.     

Survival rates in out-of-hospital cardiac arrest patients transported without prehospital return of spontaneous circulation: An observational cohort study

Background

Some Emergency Medical Services currently use just one component of the Universal Termination of Resuscitation (TOR) Guideline, the absence of prehospital return of spontaneous circulation (ROSC), as the single criteria to terminate resuscitation, which may deny transport to potential survivors.

Objective

This study aimed to report the survival to hospital discharge rate in non-traumatic, adult out-of-hospital cardiac arrest (OHCA) patients transported to hospital without a prehospital ROSC.

Methods

An observational study of OHCA patients without a prehospital ROSC who met the Universal TOR Guideline for transport to hospital with ongoing resuscitation. Multivariable logistic regression was used to determine the association of each variable with survival to hospital discharge.

Results

Of 20,207 OHCA treated by EMS, 3374 (16.4%) did not have a prehospital ROSC but met the Universal TOR guideline for transport to hospital with ongoing resuscitation. Of these patients, 122 (3.6%) survived to hospital discharge. Survival to discharge was associated with initial shockable VF/VT rhythms (OR 5.07; 95% CI 2.77–9.30), EMS-witnessed arrests (OR 3.51; 95% CI 1.73–7.15), bystander-witnessed arrests (OR 2.11; 95% CI 1.18–3.77), and public locations (OR 1.57; 95% CI 1.02–2.40).

Conclusion

In OHCA patients without a prehospital ROSC who met the Universal TOR Guideline for transport with ongoing resuscitation survival rates were above the 1% futility rate. Employing only the lack of ROSC as criteria for termination of resuscitation may miss survivors after OHCA.