Advanced Life Support Units Research Articles

Supervivencia de las paradas cardiacas extrahospitalarias atendidas por una unidad de vigilancia intensiva móvil de Asturias en 2010

ObjectiveTo evaluate attendance timings, out- and in-hospital characteristics, and survival of cardiac arrests attended by an advanced life support unit in Asturias (Spain) in 2010. Factors related to survival upon admission and at discharge were also analyzed. DesignA retrospective, observational trial was carried out involving a cohort of out-hospital cardiac arrests (OHCA) occurring between 1 January 2010 and 31 December 2010, with one year of follow-up from OHCA. SettingHealth Care Area IV of the Principality of Asturias, with a population of 342,020 in 2010. PatientsAll patients with OHCA and attended by an advanced life support unit were considered. Main variablesDemographic data, the etiology of cardiac arrest, bystander cardiopulmonary resuscitation (CPR), attendance timings and survival upon admission, at discharge and after one year. ResultsA total of 177 OHCA were included. Of these, 120 underwent CPR by the advanced life support team. Sixty-six of these cases (55%) were caused by presumed heart disease. A total of 63 patients (52.5%) recovered spontaneous circulation, and 51 (42.5%) maintained circulation upon admission to hospital. Thirteen patients (10.8%) were discharged alive. After one year, 11 patients were still alive (9.2%) - 9 of them (7.5%) with a Cerebral Performance Category (CPC) score of 1. Ventricular fibrillation and short attendance timings were related to increased survival. ConclusionsThe survival rate upon admission was better than in other series and similar at discharge. Initial rhythm and attendance timings were related. Public automated external defibrillators (AED) were not used, and bystander CPR was infrequent.

Coment on the original article. Basic and advanced life support units in Spain: analysis of the current situation

Coment on the original article. Basic and advanced life support units in Spain: analysis of the current situation

Safety and Efficacy of Prehospital Diltiazem

Introduction: Very few studies exist on the use of diltiazem in the prehospital setting. Some practitioners believe this medication is prone to causing hypotension in this setting. Our goals were to determine whether the prehospital administration of diltiazem induced hypotension and to evaluate the efficacy of the drug.Methods: Our two-tiered system is located in a suburban region of New Jersey with advanced life support (ALS) care provided by fly-car units. The ALS units do not transport patients, and all of them are hospital based. The ALS providers are employed by the hospital system. In New Jersey, all ALS care requires online medical control, including the administration of diltiazem. We retrospectively reviewed patient care records for those who were believed to be in rapid atrial fibrillation and were given diltiazem in a suburban emergeny medical services system over a 22-month period. We examined the differences between heart rate (HR) and blood pressure (BP) on the initial evaluation and on arrival to the emergency department (ED). A hypotensive response was defined as a final systolic BP (SBP) less than 90 mmHg and a drop in SBP of at least 10 mmHg. Diltiazem was considered effective if the ED HR was <100 beats per minute (bpm) or if it decreased ≥20%.Results: During the study period, 26,979 patients were transported. Of these patients, 2,488 had a documented rhythm of atrial fibrillation or atrial flutter. Of the 320 patients who received diltiazem, 42 patient encounters were excluded for incomplete data, yielding 278 patients for analysis. The average initial SBP was 139 mmHg and the average diastolic BP was 84 mmHg. The average diltiazem dosage was 16.7 mg. Two patients became hypotensive. The average initial HR was 154 bpm. On arrival to the ED, 33% of the patients had an HR < 100 bpm and 69% had a drop in HR ≥ 20%. The overall efficacy of prehospital diltiazem was 73%.Conclusion: In the prehospital setting, diltiazem is associated with a very low rate of hypotension and appears to be effective in decreasing HR adequately. Prospective studies are needed to confirm these findings.

Unidades de soporte vital básico y avanzado en España: análisis de la situación actual

To describe the type and number of emergency care ambulances integrated in the Emergency Medical System in the Spanish autonomous communities and to calculate their relationship with the assigned population. The official literature of the autonomous communities was reviewed, and the type and number of terrestrial care resources integrated in the Emergency Medical System and population data for 2011 were extracted. Secondary or specialized resources were excluded, and part-time units were computed in proportion to operational time. A total of 319 Advanced Life Support Units (ALSU) and 1,109.05 Basic Life Support Units (BLSU) were identified, of which 31.9 are provided with nursing staff. The national rate of ambulances by absolute population was 0.86 ALSU (range 0.32 to 1.44) and 2.35 BLSU (range 0.07 to 5.30) per 100,000 inhabitants. The state rate by relative population was estimated at 0.29 (range 1.06 to 30.22) and 0.08 (range 0.94 to 16.03) inhabitants/km2 for ALSU and BLSU respectively, and the national rate by surface was 1,586.2 (range 140.8 to 4204.5) and 456.2 km2 (range 44.1 to 14599.6) for ALSU and BLSU respectively. There are significant differences in the calculated rates of emergency care resources of autonomous regions over their population and area. No relation was found with the geodemographic idiosyncrasies of each territory. These differences could be caused by heterogeneity in the management of EMS or other factors not considered in this work.

Emergency Medical Services Response Time and Mortality in an Urban Setting

Background. A common tenet in emergency medical services (EMS) is that faster response equates to better patient outcome, translated by some EMS operations into a goal of a response time of 8 minutes or less for advanced life support (ALS) units responding to life-threatening events. Objective. To explore whether an 8-minute EMS response time was associated with mortality. Methods. This was a one-year retrospective cohort study of adults with a life-threatening event as assessed at the time of the 9-1-1 call (Medical Priority Dispatch System Echo- or Delta-level event). The study setting was an urban all-ALS EMS system serving a population of approximately 1 million. Response time was defined as 9-1-1 call receipt to ALS unit arrival on scene, and outcome was defined as all-cause mortality at hospital discharge. Potential covariates included patient acuity, age, gender, and combined scene and transport interval time. Stratified analysis and logistic regression were used to assess the response time–mortality association. Results. There were 7,760 unit responses that met the inclusion criteria; 1,865 (24%) were ≥8 minutes. The average patient age was 56.7 years (standard deviation = 21.5). For patients with a response time ≥8 minutes, 7.1% died, compared with 6.4% for patients with a response time ≤7 minutes 59 seconds (risk difference 0.7%; 95% confidence interval [CI]: –0.5%, 2.0%). The adjusted odds ratio of mortality for ≥8 minutes was 1.19 (95% CI: 0.97, 1.47). An exploratory analysis suggested there may be a small beneficial effect of response ≤7 minutes 59 seconds for those who survived to become an inpatient (adjusted odds ratio = 1.30; 95% CI: 1.00, 1.69). Conclusions. These results call into question the clinical effectiveness of a dichotomous 8-minute ALS response time on decreasing mortality for the majority of adult patients identified as having a life-threatening event at the time of the 9-1-1 call. However, this study does not suggest that rapid EMS response is undesirable or unimportant for certain patients. This analysis highlights the need for further research on who may benefit from rapid EMS response, whether these individuals can be identified at the time of the 9-1-1 call, and what the optimum response time is.

AP090 Cerebral flow improvement during CPR with LUCAS measured by Doppler

Great quality chest compressions are the most important maneouvers together with prompt defibrillation to guarantee critical flow to heart and brain in a sudden cardiac arrest treatment. Cerebral flow can be measured by trans-cranial doppler; normal rates for a healthy person are 60–80 cm/s. LUCAS® devices performs 5 cm depth chest compressions at a rate of 100 per minute, becoming immune to tiredness. Aim: To compare the middle cerebral artery flow measured by doppler, with or without LUCAS® chest compressor during cardio-pulmonary resuscitation. Methods: Prospective study from January 2011 to June 2011, where one prehospital advanced life support unit (ALSU) from the city of Barcelona was provided with the Toshiba Viamo portable ultrasound scanner and one physician was trained in cerebrovascular ultrasound during 1 month previously to the beggining of the study. Cerebral middle artery flow at 5–6 cm was mesured in all the sudden cardiac arrest (SCA) assisted by this trained unit in the study period, previously and after the LUCAS® device was placed. Results: 6 patients with SCA were assisted, 3 of them males (66±10.53 years old) and 3 females (48.33±22.67 years old). 1 patient with a SCA caused by a STEMI recovered spontaneous circulation (ROSC) before the ultrasound scan could be performed and his flow after ROSC was 96 cm/s. 2 young females suffered SCA as a consequence of a spontaneous subarachnoid haemorrhage (SSH) and no flow was observed with manual chest compressions nor with LUCAS®, but one of them ROSC. In the other 3 patients the median flow was 31.6±8.32 cm/s in the manual group in front of 50.6±27.12 cm/s in LUCAS® group. Conclusions: Patients with SCA due to SSH seem not to receive cerebral flow during resuscitation with manual chest compressions nor with LUCAS®. LUCAS seems to improve cerebral flow compared with manual CPR during the resuscitation of patients with a non-SSH SCA.

Quality of Cardiopulmonary Resuscitation in Out-of-hospital Cardiac Arrest Is Hampered by Interruptions in Chest Compressions—A Nationwide Prospective Feasibility Study

This prospective, observational study was designed to evaluate the quality of cardiopulmonary resuscitation (CPR) provided by health care providers to out-of-hospital cardiac arrest patients. The study compared quality of CPR provided by Basic Life Support (BLS)-capable emergency response units, and Advanced Life Support (ALS)-capable emergency response units. BLS units included two emergency medical services (EMS) providers, whereas ALS units were assisted by paramedics, nurse anesthetists, or were physician-manned.

(A310) Academic Training for Paramedics - A Unique University Based Model

IntroductionThe paramedic profession is relatively new, dating to the 1970's. In Israel, it was introduced in 1980 and paralleled the introduction of advanced life support units (ALS) to Israel's national emergency medical services (EMS), Magen David Adom (MDA).The curriculum and assigned roles were adopted with minor changes from Anglo-American systems. Initially, paramedics were assigned alongside physicians, but in recent years a growing percentage of units operate without an on-board physician. Despite the increasing complexity of required tasks and the move toward paramedic-led crews, paramedic training has changed little. Most are trained through a non-academic, certificate granting tracts. In 1998, a fully academic bachelor's degree program was launched at the Ben-Gurion University (BGU).MethodsThe programs aims, curriculum, and experience are described, based on past and current curriculum and on interviews with past and current staff and students.ResultsThe BGU program is a three year program that grants its graduates both a University BA and professional paramedic certification. The program is housed as a university department within the Faculty of Health Sciences. First year courses center on basic sciences. The second year centers on classroom and simulation-based learning of the clinical topics. The third is devoted mostly to clinical clerkships, in hospital wards in the first semester and on MDA ALS units in the second. To date, the program boasts more than 300 graduates, many attaining higher academic degrees in healthcare sciences and many who work in Israel's national EMS.DiscussionThe BGU academic paramedic training program is the only such program in Israel and one of a few worldwide. Questions regarding the increasing responsibility and task complexity require a move from certificate training to University degree granting learning and the possible contribution of such

Entrapped victims in motor vehicle collisions: characteristics and prehospital care in the city of São Paulo, Brazil

OBJECTIVE:To examine the severity of trauma in entrapped victims and to identify risk factors for mortality and morbidity.INTRODUCTION:Triage and rapid assessment of trauma severity is essential to provide the needed resources during prehospital and hospital phases and for outcome prediction. It is expected that entrapped victims will have greater severity of trauma and mortality than non‐entrapped subjects.METHODS:A transverse, case–control, retrospective study of 1203 victims of motor vehicle collisions treated during 1 year by the prehospital service in São Paulo, Brazil was carried out. All patients were drivers, comprising 401 entrapped victims (33.3%) and 802 non‐entrapped consecutive controls (66.7%). Sex, age, mortality rates, Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), corporal segments, timing of the prehospital care and resource use were compared between the groups. The results were analysed by χ2, Zres, analysis of variance and Bonferroni tests.RESULTS:Entrapped victims were predominantly men (84.8%), aged 32±13.1 years, with immediate mortality of 10.2% and overall mortality of 11.7%. They had a probability of death at the scene 8.2 times greater than that of non‐entrapped victims. The main cause of death was hemorrhage for entrapped victims (45.2%) and trauma for non‐entrapped victims. Of the entrapped victims who survived, 18.7% had a severe GCS (OR = 10.62), 12% a severe RTS (OR = 9.78) and 23.7% were in shock (OR = 3.38). Entrapped victims were more commonly transported to advanced life support units and to tertiary hospitals.CONCLUSION:Entrapped victims had greater trauma severity, more blood loss and a greater mortality than respective, non‐entrapped controls.

Quality of cardiopulmonary resuscitation in out-of-hospital cardiac arrest is hampered by interruptions in chest compressions—A nationwide prospective feasibility study

Aim of the studyQuality of cardiopulmonary resuscitation (CPR) is a critical determinant of outcome following out-of-hospital cardiac arrest. The aim of our study was to evaluate the quality of CPR provided by emergency medical service providers (Basic Life Support (BLS) capability) and emergency medical service providers assisted by paramedics, nurse anesthetists or physician-manned ambulances (Advanced Life Support (ALS) capability) in a nationwide, unselected cohort of out-of-hospital cardiac arrest cases. MethodsWe conducted a prospective, observational study of out-of-hospital cardiac arrest with non-traumatic etiology (>18 years of age) occurring from the 1st to the 31st of January 2009 and treated by the primary Danish emergency medical service operator, covering approximately 85% of the population. One hundred and ninety-one cases were eligible for analysis. Follow-up was up to one year or death. Quality of CPR was evaluated using measurements of transthoracic impedance. ResultsThe majority of patients were treated by ambulances with ALS capability (54%). Interruptions in CPR related to loading of the patient into the emergency medical service vehicle were substantial, but independent of whether patients were managed by ALS or BLS capable units (222s versus 224s, P=0.76) as were duration of interruptions during rhythm analysis alone (20s versus 22s, P=0.33) and defibrillation (24s versus 26s, P=0.07). ConclusionsNationwide, routine monitoring of transthoracic impedance is feasible. CPR is hampered by extended interruptions, particularly during loading of the patient into the emergency medical service vehicle, rhythm analysis and defibrillation.

The competency of emergency medical operation in emergency medical personnel: advanced life support Unit

This research is descriptive research based on mixed methodology. The objective is designed to study the competency of emergency medical operation in emergency medical personnel: advanced life support unit in...

Fusion of dispatching centres into one entity: effects on performance

Dispatching centres were fused into one of the 112 entity, which caused concerns regarding whether the medical calls could be processed effectively also in the new centre. We evaluated the effects of the reform on key performance criteria in medical calls. This observational study in the Helsinki Dispatching Centre consisted of two periods: Period I 2 years before the reform and Period II 2 years after. The main outcome measures were answering and call processing times, accuracy of risk assessment and appropriate use of ambulances. In Period I (n=574,276), 92.2% of all incoming phone calls were answered within 10 s and in Period II (n=758,022) 82.8% (P<0.0001). Time to dispatch a first responding fire unit increased from 98 to 113 s (P<0.0001) and an advanced life support unit in category A calls increased from 73 to 84 s (P<0.0001). In Period I 47.7%, 34.8% and 17.5% of phone calls were completed in <3, 3-5 and >5 min and in Period II 29.8%, 36.1% and 34.1% (P<0.0001). The number of three studied non-transportation call types and unnecessary lights-and-siren responses increased significantly (P<0.0001 and 0.0001, respectively). Neither the accuracy of risk assessment in the three studied call types nor the rate of telephone-guided cardiopulmonary resuscitation changed. The reform increased the total number of ambulance dispatches, prolonged answering and call processing times and had a negative effect on the appropriate use of ambulances. The accuracy of risk assessment was not affected. Evidence-based data should be the basis for the future as dispatching centre processes are shown to be vulnerable during organisational reforms.

Do All Pediatric Patients Who Have a Febrile Seizure Require Transport by Advanced Life Support?

In the state of New Jersey, all pediatric patients who are transported to the hospital by emergency medical services for seizures are evaluated by both advanced life support (ALS) and basic life support (BLS) units. The state triage protocol mandates that a paramedic unit be dispatched. The purpose of this study is establish that the subset of those patients who experience simple febrile seizures could be safely transported by BLS, subsequently freeing much needed ALS resources. This study was performed using a retrospective chart review. Seventy-one consecutive patients who experienced febrile seizures and were transported to the Bristol-Meyers-Squib Children's Hospital/Robert Wood Johnson University Hospital via ALS were included. These patients were risk stratified into groups which were analyzed for interventions, including inpatient admission, medication delivery, intubation, or respiratory support. From this analysis, we are identified factors in the history and physical examination of patients in the field that would help to classify the patient as having a "simple febrile seizure" and thus significantly lowering the risk of any potential negative outcome. Simple febrile seizure patients are suitable for transport via BLS. Further studies should be done to confirm this conclusion.

Evidence-Based Performance Measures for Emergency Medical Services Systems: A Model for Expanded EMS Benchmarking

There are few evidence-based measures of emergency medical services (EMS) system performance. In many jurisdictions, response-time intervals for advanced life support units andresuscitation rates for victims of cardiac arrest are the primary measures of EMS system performance. The association of the former with patient outcomes is not supported explicitly by the medical literature, while the latter focuses on a very small proportion of the EMS patient population andthus does not represent a sufficiently broad selection of patients. While these metrics have their place in performance measurement, a more robust method to measure andbenchmark EMS performance is needed. The 2007 U.S. Metropolitan Municipalties' EMS Medical Directors' Consortium has developed the following model that encompasses a broader range of clinical situations, including myocardial infarction, pulmonary edema, bronchospasm, status epilepticus, andtrauma. Where possible, the benefit conferred by EMS interventions is presented in the number needed to treat format. It is hoped that utilization of this model will serve to improve EMS system design anddeployment strategies while enhancing the benchmarking andsharing of best practices among EMS systems.

Presumed futility in paramedic-treated out-of-hospital cardiac arrest: An Utstein style analysis in Tampere, Finland

To report prospectively the outcome from prehospital cardiac arrest according to the Utstein template in the city of Tampere, Finland, with special reference to those patients in whom resuscitation was not attempted. In Tampere (population 203,000), a two-tiered emergency medical service (EMS) system provides first response and basic life support (BLS), supported by advanced life support (ALS) units staffed with nurse-paramedics. We analysed all out-of-hospital cardiac arrests considered for resuscitation during a 12-month period. Of 191 patients with prehospital cardiac arrest, resuscitation was not attempted in 98 patients (51%). Reasons to withhold from resuscitation were estimated futility (97 cases) and a do-not-attempt-resuscitation order (1). Sixty percent of the patients with no resuscitation had secondary signs of death, 97% had asystole as the initial cardiac rhythm and 98% had suffered an unwitnessed cardiac arrest. Resuscitation was successful in 45 of the remaining 93 patients with attempted resuscitation. Twelve patients were discharged (overall survival rate 13%), nine of them with a CPC score of 1 or 2. Fifteen patients were treated with therapeutic hypothermia. Of the bystander-witnessed cardiac arrests with VF as initial rhythm, 29% survived. The Tampere EMS system initiated resuscitation less frequently than reported from other EMS systems, but the reasons to withhold resuscitation seemed justified. The overall and Utstein's 'golden standard' survival rates were comparable with previous reports.

Initial emergency medical dispatching and prehospital needs assessment: a prospective study of the Swedish ambulance service

To evaluate the setting of priorities and patients' need for the ambulance service. A prospective, consecutive study was conducted during a 6-week period. The ambulance staff completed a questionnaire assessing each patient's need for prehospital care. In addition to the questionnaire, data were extracted from the ambulance medical records for each case. The study included 1977 ambulance assignments. The results show that there is a substantial safety margin in the priority assessments made by the emergency medical dispatch operators, where the ambulance staff support the safety margin for initial priorities, despite the lack of at-the-scene confirmation. At-the-scene assessments indicated that 10% of all patients had potentially life-threatening conditions or no signs of life, but the advanced life support units were not systematically involved in these serious cases. The results even showed that one-third of the patients for whom an ambulance was assigned did not need the ambulance service according to the assessment made by the ambulance staff. Using the criteria-based dispatch protocol, the personnel at the emergency medical dispatch centres work with a safety margin in their priority assessments for ambulance response. Generally, this 'overtriage' and safety margin for initial priority settings were supported as appropriate by the ambulance staff. According to the judgement of the ambulance staff, one-third of all the patients who were assigned an ambulance response did not require ambulance transport.

Outcome after out-of-hospital cardiac arrest in a physician-staffed emergency medical system according to the Utstein style

Despite a large amount of data assessing outcomes of out-of-hospital cardiac arrests (OHCAs), little information is available about physician-staffed emergency medical service (EMS) systems. The aim of our study was to investigate the impact of a physician on the outcome of patients after OHCA. This is a prospective, observational study that included 539 consecutive patients (63.9 +/- 19.1 years old; 349 males) with OHCA in the community of Dachau (135,000 inhabitants) in whom resuscitation was attempted between January 2000 and January 2006 according to Utstein style. Patients were followed up to hospital discharge. The primary end point of the study was that the patients was discharged alive from hospital. Of 412 patients with an OHCA, 180 (43.7%) were admitted to hospital, and 47 (11.4%) were discharged alive. Resuscitation was started by a physician in 117 (28.4%) patients, by a layperson in 118 (28.6%), or by an EMS personnel in 177 (43.0%). A total of 18 patients (18.6%) treated by physicians, 13 patients (8.0%) treated by EMS personnel (P = .02 vs treatment by physician), and 16 patients (16.5%) resuscitated by laypersons were discharged from hospital (P = .8 vs treatment by physician). In 105 patients with bystander-witnessed OHCA of cardiac origin with shockable rhythm, the discharge rate was 32.4% (n = 34). Multivariate analysis identified ventricular fibrillation on first electrocardiogram, observed OHCA, short response time intervals but not the unit that performed the first resuscitation attempt as independent predictors of survival. A physician on board of the advanced life support unit was not identified as an independent factor of improved survival.

Clinical consequences of the introduction of mechanical chest compression in the EMS system for treatment of out-of-hospital cardiac arrest—A pilot study

To evaluate the outcome among patients suffering from out-of-hospital cardiac arrest (OHCA) after the introduction of mechanical chest compression (MCC) compared with standard cardiopulmonary resuscitation (SCPR) in two emergency medical service (EMS) systems. The inclusion criterion was witnessed OHCA. The exclusion criteria were age < 18 years, the following judged etiologies behind OHCA: trauma, pregnancy, hypothermia, intoxication, hanging and drowning or return of spontaneous circulation (ROSC) prior to the arrival of the advanced life support (ALS) unit. Two MCC devices were allocated during six-month periods between four ALS units for a period of two years (cluster randomisation). In all, 328 patients fulfilled the criteria for participation and 159 were allocated to the MCC tier (the device was used in 66% of cases) and 169 to the SCPR tier. In the MCC tier, 51% had ROSC (primary end-point) versus 51% in the SCPR tier. The corresponding values for hospital admission alive (secondary end-point) were 38% and 37% (NS). In the subset of patients in whom the device was used, the percentage who had ROSC was 49% versus 50% in a control group matched for age, initial rhythm, aetiology, bystander-/crew-witnessed status and delay to CPR. The percentage of patients discharged alive from hospital after OHCA was 8% versus 10% (NS) for all patients and 2% versus 4%, respectively (NS) for the patients in the subset (where the device was used and the matched control population). In this pilot study, the results did not support the hypothesis that the introduction of mechanical chest compression in OHCA improves outcome. However, there is room for further improvement in the use of the device. The hypothesis that this will improve outcome needs to be tested in further prospective trials.

Out-of-hospital cardiac arrests in Tampere, Finland according to the Utstein style

Purpose of the study: This is a prospective follow-up study of out-of-hospital cardiac arrests in the city of Tampere, performed according to the revised Utstein style.1. Material and methods: In Tampere (population 203,000), a two-tiered emergency medical service (EMS) provides first response and basic life support (BLS), which is supported by two advanced life support (ALS) units staffed with nurse-paramedics. We analysed all out-of-hospital cardiac arrests considered to be resuscitated in a recent 12-month follow-up.

Epidemiology of out-of-hospital cardiac arrest attended by an emergency medical services system

Purpose of the study: To determine the epidemiology and aetiology of out-of-hospital cardiac arrest attended by an Emergency Medical Services system. Materials and methods: A prospective cohort study of 38 consecutive standardised reports on out-of-hospital resuscitation attempts from 1 January 2005 to 30 June 2005 was conducted according to the Utstein style. The setting of the trial was an urban-suburban Emergency Medical Services system with central dispatching. Patients received standard care according to the recommendations of European Resuscitation Council. Results: In all, 53% of the cardiac arrests were of presumed cardiac aetiology. The mean age was 63 years. Seventy percent of the patients were male. Sixty-eight percent of the cases were bystander-witnessed and 40% of them received basic cardiopulmonary resuscitation. Asystole was the first electrical rhythm recorded in 63% of the patients and Ventricular Fibrillation/Tachycardia in 13.2% of patients. The proportion of patients with return of spontaneous circulation was 13% (5/38). All of them were admitted alive to the hospital. The median time intervals from the receipt of the call to the arrival of a first response advanced life support unit at the patient's side were 11 min. The median interval between the onset of the cardiac arrest and the beginning of the advanced care was 13,5 min. None of the patients received automated external defibrillation. Conclusions: There is an opportunity to strengthen the chain of survival by reducing the response time interval and increasing the use of bystander cardiopulmonary resuscitation. A Public Access Defibrillation program will need to be considered.