All-Japan Utstein Registry Research Articles

Relationship between cardiopulmonary resuscitation duration and outcomes in children with drowning-induced cardiac arrest

BackgroundDue to the difficulty in making the decision to discontinue resuscitation efforts, clinicians often perform prolonged cardiopulmonary resuscitation (CPR) in children who have drowned. This study investigated the relationship between out-of-hospital CPR duration and neurological outcomes in children with drowning-induced cardiac arrest. MethodsThis retrospective cohort study used data from the All-Japan Utstein Registry from 2013 to 2021. We included patients aged ≤18 years with drowning-induced cardiac arrest who underwent CPR via emergency medical services. The study's primary outcome was a favorable neurological outcome (Cerebral Performance Category score of 1 or 2) at 1 month. We also calculated the dynamic proportion of 1-month outcomes as a function of out-of-hospital CPR duration. Moreover, we determined the sensitivity, specificity, and positive predictive value of 33 min of out-of-hospital CPR, which is the time point at which primary analysis showed a plateau in the neurological outcomes. ResultsOf 14,849 children included in the registry, 992 cases of drowning-induced cardiac arrest were analyzed. The median out-of-hospital CPR duration was 20 (range, 2–164) min, with only 35 (3.5 %) patients showing favorable neurological outcomes at 1 month. The proportion of favorable neurological outcomes decreased rapidly for up to 33 min of out-of-hospital CPR and then plateaued to 0.3 %; only three patients achieved favorable neurological outcomes after 33 min of CPR. An out-of-hospital CPR duration of >33 min was associated with poor neurological outcomes (sensitivity, 0.17 [95 % confidence interval: 0.15–0.20]; specificity, 0.91 [0.77–0.98]; and positive predictive value, 0.98 [0.95–1.00]). ConclusionsPrehospital EMS-initiated CPR duration for children with drowning-induced cardiac arrest was inversely associated with one-month favorable neurological outcomes. Favorable neurological outcomes after >33 min of out-of-hospital CPR were extremely rare, though accurately predicting the outcome remains challenging.

Regional Comparison in Cerebral Performance Outcome of Out-of-Hospital Cardiac Arrest: The All-Japan Utstein Registry.

Past studies have reported regional differences in the prognosis of out-of-hospital cardiopulmonary arrest (OHCA) in Japan, but there is a lack of sufficient information to explain the changes in neurological prognosis over time. Using the All-Japan Utstein Registry, a nationwide population-based OHCA database, we included non-traumatic OHCA patients resuscitated by emergency responders across all seven regions from January 1, 2011, to December 31, 2017. The primary endpoint was a favorable neurological outcome one month after cardiac arrest, compared among these seven regions. The secondary endpoint was one-month survival after OHCA. There were 880,043 OHCA patients, of whom 721,455 (82.0%) were included in the analysis. Overall, a total of 17,685 (2.45%) patients survived with favorable neurological outcomes. Unadjusted neurological favorable outcomes varied regionally, ranging from 1.64% to 3.37% (rate difference: 1.73%; 95%CI: 1.57-1.89%). The East and Northeast had a significantly lower rate compared to the Midwest region (unadjusted rate ratio: 0.73; 95%CI: 0.70-0.76; p<0.001, 0.63; 95%CI: 0.59-0.67; p<0.001, respectively). The significant difference remained after adjustment for patient factors and prehospital factors (adjusted rate ratio: 0.68; 95%CI: 0.64-0.72, p<0.01, 0.70; 95%CI: 0.67-0.73, p<0.01, respectively). The secondary outcome, survival at one month, also showed similar regional differences. In this post-hoc analysis, nationwide, population-based study in Japan, we found that regional differences in the neurologic prognosis of OHCA patients persist. The difference has narrowed from previous years, but the causes still need to be investigated and improved in the future.

Effects of Post-Hospital Arrival Factors on Out-of-Hospital Cardiac Arrest Outcomes During the COVID-19 Pandemic.

The relationship between post-hospital arrival factors and out-of-hospital cardiac arrest (OHCA) outcomes remains unclear. This study assessed the impact of post-hospital arrival factors on OHCA outcomes during the COVID-19 pandemic using a prediction model. In this cohort study, data from the All-Japan Utstein Registry, a nationwide population-based database, between 2015 and 2021 were used. A total of 541,781 patients older than 18 years old who experienced OHCA of cardiac origin were included. The primary exposure was trends in COVID-19 cases. The study compared the predicted proportion of favorable neurologic outcomes 1 month after resuscitation with the actual outcomes. Neurologic outcomes were categorized based on the Cerebral Performance Category score (1, good cerebral function; 2, moderate cerebral function). The prediction model, which had an area under the curve of 0.96, closely matched actual outcomes in 2019. However, a significant discrepancy emerged after the pandemic began in 2020, where outcomes continued to deteriorate as the virus spread, exacerbated by both pre- and post-hospital arrival factors. Post-hospital arrival factors were as important as pre-hospital factors in adversely affecting the prognosis of patients following OHCA during the COVID-19 pandemic. The results suggest that the overall response of the healthcare system needs to be improved during infectious disease outbreaks to improve outcomes.

Long-Term Impact of the Kumamoto Earthquake on Out-of-Hospital Cardiac Arrest With Cardiac and Non-Cardiac Origins - An Interrupted Time Series Analysis.

Possible etiologies of out-of-hospital cardiac arrest (OHCA), including aortic dissection, ruptured aortic aneurysms, and pulmonary embolism, may be classified as non-cardiac causes. We investigated whether cardiac and non-cardiac OHCAs increased following the Kumamoto earthquake and whether the impact on OHCAs extended to regions far from the epicenter. We prospectively analyzed a nationwide registry of patients who experienced OHCAs between January 2013 and December 2019. Data from cases registered in 7 prefectures, including Kumamoto (Kyushu region; n=82,060), in the All-Japan Utstein Registry were analyzed for OHCAs of cardiac and non-cardiac origin. The numbers of OHCAs before and after the Kumamoto earthquake were compared using an interrupted time series analysis. The incidence of both cardiac (rate ratio [RR] 1.22) and non-cardiac (RR 1.27) OHCAs in Kumamoto Prefecture increased after the earthquake. The difference disappeared when the analysis was limited to patients with non-cardiac OHCAs with a clear cause of cardiac arrest. The number of cardiac and non-cardiac OHCAs did not increase in other prefectures within the Kyushu region. The Kumamoto earthquake led to an increase in the incidence of cardiac and non-cardiac OHCAs. However, this was attenuated by increasing distance from the epicenter. Except for cardiac causes, cases complicated by earthquake-related events may include non-cardiac OHCAs due to vascular diseases that might be overlooked.

Neurological prognosis prediction upon arrival at the hospital after out-of-hospital cardiac arrest: R-EDByUS score

AimTo develop a new scoring model for patients with cardiogenic out-of-hospital cardiac arrest (OHCA) to facilitate neurological prognosis prediction upon hospital arrival by using prehospital resuscitation features alone. MethodsBetween 2005 and 2019, we enrolled 942,891 adult patients with OHCA of presumed cardiac aetiology from the All-Japan Utstein Registry. Scoring models applied prehospital resuscitation features a priori from the variables the American College of Cardiology algorithm including age, duration to return of spontaneous circulation (ROSC) or hospital arrival, no bystander cardiopulmonary resuscitation (CPR), unwitnessed arrest, and nonshockable rhythm (R-EDByUS score) to predict unfavorable neurological outcomes defined as Cerebral Performance Category 3, 4, or 5 at 1 month. We created nomograms as a “Regression-based model,” and created a “Simplified model” in which points were assigned by category for predicting unfavorable neurological outcomes for both the prehospital ROSC cohort (67,064 patients) and the ongoing CPR cohort (875,827 patients). For internal validation, bootstrap optimism-corrected estimates of predictive performance were calculated. ResultsA total of 46,971 (70.0%) and 870,991 (99.4%) patients in the prehospital ROSC and ongoing CPR cohorts, respectively, had unfavorable neurological outcomes. In the prehospital ROSC cohort, the C-statistics of the Regression-based and Simplified models were 0.851 and 0.842, and the bootstrap-validated C-statistics were 0.852 and 0.841, respectively. In the ongoing CPR cohort, the C-statistics of the Regression-based and Simplified models were 0.872 and 0.865, and the bootstrap-validated C-statistics were 0.852 and 0.841, respectively. ConclusionsThe R-EDByUS score accurately predicted the neurological prognosis of cardiogenic OHCA upon hospital arrival.

Impact of the COVID-19 pandemic on pediatric out-of-hospital cardiac arrest outcomes in Japan

This study investigates the impact of the COVID-19 pandemic on pediatric out-of-hospital cardiac arrest (OHCA) outcomes in Japan, aiming to address a critical research gap. Analyzing data from the All-Japan Utstein registry covering pediatric OHCA cases from 2018 to 2021, the study observed no significant changes in one-month survival, neurological outcomes, or overall performance when comparing the pre-pandemic (2018–2019) and pandemic (2020–2021) periods among 6765 cases. However, a notable reduction in pre-hospital return of spontaneous circulation (ROSC) during the pandemic (15.1–13.1%, p = .020) was identified. Bystander-initiated chest compressions and rescue breaths declined (71.1–65.8%, 22.3–13.0%, respectively; both p < .001), while bystander-initiated automated external defibrillator (AED) use increased (3.7–4.9%, p = .029). Multivariate logistic regression analyses identified factors associated with reduced pre-hospital ROSC during the pandemic. Post-pandemic, there was no noticeable change in the one-month survival rate. The lack of significant change in survival may be attributed to the negative effects of reduced chest compressions and ventilation being offset by the positive impact of widespread AED availability in Japan. These findings underscore the importance of innovative tools and systems for safe bystander cardiopulmonary resuscitation during a pandemic, providing insights to optimize pediatric OHCA care.

Development and validation of a prehospital termination of resuscitation (TOR) rule for out - of hospital cardiac arrest (OHCA) cases using general purpose artificial intelligence (AI)

BackgroundPrehospital identification of futile resuscitation efforts (defined as a predicted probability of survival lower than 1%) for out-of-hospital cardiac arrest (OHCA) may reduce unnecessary transport. Reliable prediction variables for OHCA 'termination of resuscitation' (TOR) rules are needed to guide treatment decisions. The Universal TOR rule uses only three variables (Absence of Prehospital ROSC, Event not witnessed by EMS and no shock delivered on the scene) has been externally validated and is used by many EMS systems. Deep learning, an artificial intelligence (AI) platform is an attractive model to guide the development of TOR rule for OHCA. The purpose of this study was to assess the feasibility of developing an AI-TOR rule for neurologically favorable outcomes using general purpose AI and compare its performance to the Universal TOR rule. Methods: We identified OHCA cases of presumed cardiac etiology who were 18 years of age or older from 2016 to 2019 in the All-Japan Utstein Registry. We divided the dataset into 2 parts, the first half (2016–2017) was used as a training dataset for rule development and second half (2018–2019) for validation. The AI software (Prediction One®) created the model using the training dataset with internal cross-validation. It also evaluated the prediction accuracy and displayed the ranking of influencing variables. We performed validation using the second half cases and calculated the prediction model AUC. The top four of the 11 variables identified in the model were then selected as prognostic factors to be used in an AI-TOR rule, and sensitivity, specificity, positive predictive value, and negative predictive value were calculated from validation cohort. This was then compared to the performance of the Universal TOR rule using same dataset. ResultsThere were 504,561 OHCA cases, 18 years of age or older, 302,799 cases were presumed cardiac origin. Of these, 149,425 cases were used for the training dataset and 153,374 cases for the validation dataset. The model developed by AI using 11 variables had an AUC of 0.969, and its AUC for the validation dataset was 0.965. The top four influencing variables for neurologically favorable outcome were Prehospital ROSC, witnessed by EMS, Age (68 years old and younger) and nonasystole. The AUC calculated using the 4 variables for the AI-TOR rule was 0.953, and its AUC for the validation dataset was 0.952 (95%CI 0.949 –0.954). Of 80,198 patients in the validation cohort that satisfied all four criteria for the AI-TOR rule, 58 (0.07%) had a neurologically favorable one-month survival. The specificity of AI-TOR rule was 0.990, and the PPV was 0.999 for predicting lack of neurologically favorable survival, both the specificity and PPV were higher than that achieved with the universal TOR (0.959, 0.998). ConclusionsThe accuracy of prediction models using AI software to determine outcomes in OHCA was excellent and the AI-TOR rule’s variables from prediction model performed better than the Universal TOR rule. External validation of our findings as well as further research into the utility of using AI platforms for TOR prediction in clinical practice is needed.

Impact of Updating the Cardiopulmonary Resuscitation Guidelines on Out-of-Hospital Shockable Cardiac Arrest: A Population-Based Cohort Study in Japan.

International consensus on cardiopulmonary resuscitation (CPR) and emergency cardiovascular care science and treatment recommendations (CoSTR) have reported updates on CPR maneuvers every 5 years since 2000. However, few national population-based studies have investigated the comprehensive effectiveness of those updates for out-of-hospital cardiac arrest due to shockable rhythms. The primary objective of the present study was to determine whether CPR based on CoSTR 2005 or 2010 was associated with improved outcomes in Japan, as compared with CPR based on Guidelines 2000. From the All-Japan Utstein Registry between 2005 and 2015, we included 73 578 adults who had shockable out-of-hospital cardiac arrest witnessed by bystanders or emergency medical service responders. The study outcomes over an 11-year period were compared between 2005 of the Guidelines 2000 era, from 2006 to 2010 of the CoSTR 2005 era, and from 2011 to 2015 of the CoSTR 2010 era. In the bystander-witnessed group, the adjusted odds ratios for favorable neurological outcomes at 30 days after out-of-hospital cardiac arrest by enrollment year increased year by year (1.19 in 2006, and 3.01 in 2015). Similar results were seen in the emergency medical service responder-witnessed group and several subgroups. Compared with CPR maneuvers for shockable out-of-hospital cardiac arrest recommended in the Guidelines 2000, CPR maneuver updates in CoSTR 2005 and 2010 were associated with improved neurologically intact survival year by year in Japan. Increased public awareness and greater dissemination of basic life support may be responsible for the observed improvement in outcomes. URL: https://www.umin.ac.jp/ctr/; Unique identifier: 000009918.

Left-digit bias in out-hospital cardiac arrest: The JCS-ReSS study.

The left-digit bias (LDB), a numerical-related cognitive bias, not only potentially influences decision-making among the general public but also that of medical practitioners. Few studies have investigated its role in out-of-hospital cardiac arrest (OHCA). We retrospectively included all consecutive patients with OHCA witnessed by family members registered in the All-Japan Utstein Registry of the Fire and Disaster Management Agency between January 1, 2005, and December 31, 2020. Target outcomes were the percentage of bystander cardiopulmonary resuscitation (BCPR) performed by family members or paramedics and the percentage of prehospital physician-staffed advanced cardiac life support (ACLS). Using a nonparametric regression discontinuity methodology, we examined whether a significant change occurred in the percentages of BCPR and ACLS at the age thresholds of 60, 70, 80, and 90 years, which would indicate the presence of LDB. Of the 1,930,273 OHCA cases in the All-Japan Utstein Registry, 384,200 (19.9%) cases witnessed by family members were analyzed. The mean age was 75.8 years (±SD 13.7), with 38.0% (n = 146,137) female. We identified no discontinuities in the percentages of chest compressions, mouth-to-mouth ventilation, or automated external defibrillator (AED) usage by family members for the age thresholds of 60, 70, 80, and 90 years. Moreover, no discontinuities existed in the percentages of chest compressions, advanced airway management, and AED usage by paramedics or prehospital ACLS by physicians for any of the age thresholds. In conclusion, our study did not find any evidence that age-related LDB affects medical decision-making in patients with OHCA.

Temporal trends in neurologically intact survival after paediatric out-of-hospital cardiac arrest: a nationwide population-based observational study in Japan

Abstract Background/Introduction Out-of-hospital cardiac arrest (OHCA) in children is associated with poor outcomes. However, the temporal trends in survival, especially neurologically intact survival in paediatric patients with OHCA, remain unclear. Purpose To examine temporal trends in neurologically intact survival in paediatric patients with OHCA for over 16 years. Methods We reviewed the data of 27,202 children (age &amp;lt;18 years) who experienced OHCA and were treated by emergency medical service providers. Data were obtained from the All-Japan Utstein Registry from January 2005 to December 2020. We analysed the temporal trends in the 1-month neurologically intact survival (cerebral performance category scale 1 or 2: CPC 1–2) rate over time. Subgroup analyses for outcomes were performed by type of bystander cardiopulmonary resuscitation (CPR), dispatcher-assisted CPR, age group (infant [&amp;lt;1 year], child [1–11 years], adolescent [12–17 years]), witnessed status, and cause of arrest. The primary endpoint was the 1-month neurologically intact survival. Results The frequency of bystander CPR significantly increased from 50.0% in 2005 to 63.1% in 2020 and the frequency of dispatcher-assisted chest compression-only CPR (CC-CPR) significantly increased from 7.7% to 40.6% (both p for trend &amp;lt;0.0001). The rate of initial shockable rhythm significantly decreased from 5.0% to 3.4% (p for trend &amp;lt;0.0001). The multivariate logistic regression model showed that calendar year, age, witnessed arrest, presence of bystander CPR, initial shockable rhythm, and non-cardiac causes were associated with increased odds of CPC 1–2. The overall crude rates of 1-month CPC 1–2 significantly increased from 4.9% in 2005 to 11.0% in 2020 (p for trend &amp;lt;0.0001). In patients who received standard CPR with rescue breathing and CC-CPR, the 1-month CPC 1–2 rate significantly increased from 8.0% to 24.2% and 4.7% to 10.8% (p for trend &amp;lt;0.0001), respectively. The rate of CPC 1–2 in patients who underwent dispatcher-assisted CPR also increased from 4.4% to 9.2% (p for trend &amp;lt;0.0001). With regards to patient age groups, the rate of 1-month CPC 1–2 significantly increased from 2.4% in 2005 to 7.5% in 2020 for infants, 6.0% to 14.8% for children, and 6.5% to 11.4% for adolescents (all p for trend &amp;lt;0.0001). For witnessed arrest, the rate of 1-month CPC 1–2 significantly increased from 9.9% to 24.9% for witnessed arrest and 2.7% to 3.1% for unwitnessed arrest. The rate of 1-month CPC 1–2 significantly increased from 4.9% to 13.8% for presumed cardiac causes and 5.0% to 9.6% for non-cardiac causes. Conclusions The 1-month neurologically intact survival rate significantly increased from 2005 to 2020 for paediatric patients with OHCA in Japan, regardless of bystander CPR type, age, witnessed status, and cause of arrest. A frequency of dispatcher-assisted CC-CPR rate increase of almost five-fold over time was associated with a two-fold increase in the overall 1-month CPC 1–2 rate over time.

Association of prehospital tracheal intubation with outcomes comparing to supraglottic airway device during out-of-hospital cardiac arrest by drowning: nationwide cohort study in Japan

Abstract Background/Introduction Drowning is the third leading cause of unintentional injury death, which causes more than 500,000 deaths annually worldwide. Several studies have examined the impact of tracheal intubation for outcomes in out-of-hospital cardiac arrest (OHCA) patients, however few studies examined it in OHCA patients by drowning. Purpose To compare survival outcomes among adults OHCA patients by drowning between tracheal intubation and supraglottic airway device. Methods This study compared the outcome of OHCA patients by drowning according to the airway management using Japanese nationwide, population-based registry (All-Japan Utstein Registry). From 2014 to 2020, consecutive adult OHCA patients were included. Patients who received tracheal intubation during cardiopulmonary resuscitation (CPR) were matched with patients treated with supraglottic airway device on the basis propensity scores in a 1:1 ratio, with a 0.2 caliper width. Propensity score was calculated by logistic regression model using following variables; year, prefectural preference of ETI use, age, sex, witnessed status, those who witnessed (By family, citizen, EMS, others), AED use, bystander-initiated CPR, prehospital involvement of physician, defibrillation by EMS, administration of adrenaline, time from call to CPR, first rhythm documented by EMS. The outcome measures were return of spontaneous circulation, survival at one month, and favorable neurological outcome defined as cerebral performance status 1 or 2. Results Of the 11, 703 eligible patients, 4467 (38.2%) and 7236 (61.8%) received tracheal intubation and supraglottic airway device during CPR, respectively. After propensity score matching, 3566 patients in each cohort were matched. The return of spontaneous circulation was higher in those with tracheal intubation compared with those with supraglottic airway device: 207/3566 (5.8%) versus 167/3566 (4.7%) (odds ratio 1.25, 95% confidence interval[CI] 1.02 to 1.55). There was no difference between the groups in one-month survival and favorable neurological outcome: 32/3566 (0.90%) versus 34/3566 (0.95%) (odds ratio 0.94, 95% CI 0.58 to 1.53), and 9/3566 (0.25%) versus 8/3566 (0.22%) (odds ratio 1.13, 95% CI 0.43 to 2.92), respectively. Conclusions In the propensity score matched study for adult OHCA by drowning, tracheal intubation was associated with the return of spontaneous circulation, whereas it was not associated with survival and favorable neurological outcome at one month compared to those with supraglottic airway device. Further studies such as to investigate the heterogeneity of the effect of intubation during the resuscitation might be mandated for the improvement of the outcome among the OHCA patients by drowning.Out-of-hospital cardiac arrest outcomes

Termination-of-resuscitation rule in the emergency department for patients with initial pulseless electrical activity after out-of-hospital cardiac arrest

Abstract Background/Introduction In several Asian countries including Japan, emergency medical service (EMS) providers are prohibited from performing field termination-of-resuscitation (TOR) in patients with refractory out-of-hospital cardiac arrest (OHCA). In 2022, we developed a TOR rule in the emergency department for patients with initial asystole after refractory OHCA, which includes three criteria: unwitnessed arrest, EMS-initiated cardiopulmonary resuscitation (CPR) duration was more than 20 min, and there was no prehospital return of spontaneous circulation (ROSC). However, until now a TOR rule in the emergency department for patients with initial pulseless electrical activity (PEA) has not been developed. Purpose This study aimed to develop and validate a TOR rule in the emergency department for patients with initial PEA after refractory OHCA. Methods We analysed the records of 137,230 adult patients (≥18 years-old) with initial PEA from the nationwide all-Japan Utstein registry from 2016 to 2020. Patients were divided into two groups: development (n=109,642, 2016 to 2019) and validation (n=27,588, 2020). The primary outcome measures were specificity, false positive rate (FPR), and positive predictive value (PPV) of the TOR rule for patients with initial PEA in the emergency department for predicting 1-month mortality. Using recursive partitioning analysis, we developed a new TOR rule for patients with initial PEA after OHCA. Results The overall 1-month survival rate of the participants was 7.4% (95% confidence interval [CI], 7.2–7.5%). Recursive partitioning analysis for the development group in predicting 1-month mortality revealed that a TOR rule for patients with PEA could be defined if patients with OHCA met all the following four criteria immediately after hospital arrival: (1) unwitnessed arrest by any laypersons, (2) EMS-initiated CPR duration more than 20 min, (3) no prehospital ROSC, and (4) age greater than or equal to 80 years. The specificity, FPR, and PPV of the rule for predicting 1-month mortality were 99.1% (95% CI, 98.9–99.3%), 0.87% (95% CI, 0.69–1.09%), and 99.2% (95% CI, 98.9–99.3%), respectively. The proportion of patients who fulfilled the rule and the area under the receiver operating curve (AUC) was 7.8% (95% CI, 7.7–8.0%), and 0.80 (95% CI, 0.79–0.80), respectively. In the validation group, the specificity, FPR, PPV, proportion of patients who met the rule, and AUC were 99.1% (95% CI, 98.5–99.4%), 0.93% (95% CI, 0.58–1.49%), 99.3% (95% CI, 98.8–99.5%), 8.3% (95% CI, 8.0–8.6%), and 0.789 (95% CI, 0.775–0.797), respectively. Conclusions We developed and validated a TOR rule in the emergency department for patients with initial PEA after OHCA. The rule includes four criteria (unwitnessed arrest, EMS-initiated CPR duration was more than 20 min, no prehospital ROSC, and age was greater than or equal to 80 years) with a more than 99% predictor of 1-month mortality.

Abstract 295: Predicting Outcomes in Adult Patients With Out-of-Hospital Cardiac Arrest; Results From the All-Japan Utstein Registry

Background: The recent cardiopulmonary resuscitation (CPR) Guideline addressed that there was no evidence to clearly define what should constitute selected patients in case of performing invasive CPR, such as extracorporeal CPR, for patients with cardiac arrest (CA). However, emergency physicians often need to determine the treatment strategy immediately upon arrival in emergency departments. The present study aimed to clarify the helpful factor of prehospital care to predict adult CA patients' prognosis using the All-Japan Utstein Registry data, a prospective, nationwide, population-based registry of out-of-hospital CA (OHCA). Methods: From the data of this registry, between 2005 and 2020, we included adult OHCA patients due to cardiac etiology. The endpoint was the favorable neurological outcome at 30 days after OHCA. The multivariable logistic regression analysis included potential confounding factors based on biological plausibility and previous studies. We scored based on the odds ratio. Receiver operating characteristic analysis was performed, and the area under the curve (AUC) was calculated for factors of the total score in order to assess the 30-day neurological outcome. Results: Of the 1,930,273 patients registered in this Registry, the data of 1,099,908 patients were included in this analysis. The table showed the adjusted odds ratio for 30-day favorable neurological outcomes in OHCA patients in the multivariate analysis, and the score based on the odds ratio. The AUC of the total scores was 0.956 (p &lt; 0.001) with a cutoff value of 7, a sensitivity of 92%, and a specificity of 88%. In the case of this total score of less than 7, the 30-day favorable neurological outcome in CA patients was significantly low (total score &lt; 7 vs. total score &gt; 7 = 0.3% vs. 18.7%: p&lt;0.001). Conclusion: This score might be a helpful factor in prehospital care information in CA patients to determine the treatment strategy upon arrival in emergency departments.

Impact of Heavy Snowfall on Emergency Transport and Prognosis of Out-of-Hospital Cardiac Arrest Patients: A Nation-Wide Cohort Study.

Out-of-hospital cardiac arrest (OHCA) is a significant global cause of mortality, and Emergency Medical Services (EMS) response interval is critical for survival and a neurologically-favorable outcome. Currently, it is unclear whether EMS response interval, neurologically-intact survival, and overall survival differ between snowy and non-snowy periods at heavy snowfall areas. A nation-wide population-based cohort of OHCA patients, registered from 2017 through 2019 in the All-Japan Utstein Registry, was divided into four groups according to areas (heavy snowfall area or other area) and seasons (winter or non-winter): heavy snowfall-winter, heavy snowfall-non-winter, other area-winter, and other area-non-winter. The first coprimary outcome was EMS response interval, and the secondary coprimary outcome was one-month survival and a neurologically-favorable outcome at one month. A total of 337,781 OHCA patients were divided into four groups: heavy snowfall-winter (N = 15,627), heavy snowfall-non-winter (N = 97,441), other area-winter (N = 32,955), and other area-non-winter (N = 191,758). Longer EMS response intervals (>13 minutes) were most likely in the heavy snowfall-winter group (OR = 1.86; 95% CI, 1.76 to 1.97), and also more likely in heavy snowfall areas in non-winter (OR = 1.44; 95% CI, 1.38 to 1.50). One-month survival in winter was worse not only in the heavy snowfall area (OR = 0.86; 95% CI, 0.78 to 0.94) but also in other areas (OR = 0.91; 95% CI, 0.87 to 0.94). One-month neurologically-favorable outcomes were also comparable between heavy snowfall-winter and other area-non-winter groups. This study showed OHCA in heavy snowfall areas in winter resulted in longer EMS response intervals. However, heavy snowfall had little effect on one-month survival or neurologically-favorable outcome at one month.

Sex- and Age-Based Disparities in Public Access Defibrillation, Bystander Cardiopulmonary Resuscitation, and Neurological Outcome in Cardiac Arrest

ImportanceYounger females with out-of-hospital cardiac arrest (OHCA) in public locations have less likelihood to receive public access defibrillation and bystander cardiopulmonary resuscitation (CPR). However, the association between age- and sex-based disparities and neurological outcomes remains underexamined.ObjectiveTo investigate the association between sex and age and the rate of receiving bystander CPR, automated external defibrillator defibrillation, and neurological outcomes in patients with OHCA.Design, Setting, and ParticipantsThis cohort study used the All-Japan Utstein Registry, a prospective, population-based, nationwide database in Japan containing data on 1 930 273 patients with OHCA between January 1, 2005, and December 31, 2020. The cohort comprised patients with OHCA of cardiac origin that was witnessed by citizens and treated by emergency medical service personnel. The data were analyzed from September 3, 2022, to May 5, 2023.ExposureSex and age.Main Outcomes and MeasuresThe primary outcome was favorable neurological outcome at 30 days after an OHCA. Favorable neurological outcome was defined as a Cerebral Performance Category score of 1 (indicating good cerebral performance) or 2 (indicating moderate cerebral disability). The secondary outcomes were the rates of receiving public access defibrillation and bystander CPR.ResultsThe 354 409 included patients who experienced bystander-witnessed OHCA of cardiac origin had a median (IQR) age of 78 (67-86) years and 136 520 were females (38.5%). The rate of receiving public access defibrillation was higher in males than females (3.2% vs 1.5%; P &amp;amp;lt; .001). Stratified by age, age- and sex-based disparities in prehospital lifesaving interventions by bystanders and in neurological outcomes were observed. Although younger females had a lower rate of receiving public access defibrillation and bystander CPR than males, younger females had a higher favorable neurological outcome compared with males of the same age (odds ratio [OR], 1.19; 95% CI, 1.08-1.31). In younger females with OHCA that was witnessed by nonfamily bystanders, receiving public access defibrillation (OR, 3.51; 95% CI, 2.34-5.27) or bystander CPR (OR, 1.62; 95% CI, 1.20-2.22) was associated with a favorable neurological outcome.Conclusions and RelevanceResults of this study suggest a pattern of significant sex- and age-based differences in bystander CPR, public access defibrillation, and neurological outcomes in Japan. Improvement in neurological outcomes in patients with OHCA, especially younger females, was associated with increased use of public access defibrillation and bystander CPR.

Identifying individuals satisfying the termination of resuscitation rule but having potential to achieve favourable neurological outcome following out-of-hospital cardiac arrest

AimTo develop a simple scoring model that identifies individuals satisfying the termination of resuscitation (TOR) rule but having potential to achieve favourable neurological outcome following out-of-hospital cardiac arrest (OHCA). MethodsThis study analysed the All-Japan Utstein Registry from 1 January 2010 to 31 December 2019. We identified patients satisfying basic life support (BLS) and advanced life support (ALS) TOR rules and determined factors associated with favourable neurological outcome (cerebral performance category scale of 1 or 2) for each cohort using multivariable logistic regression analysis. Scoring models were derived and validated to identify patient subgroups that might benefit from continued resuscitation efforts. ResultsAmong 1,695,005 eligible patients, 1,086,092 (64.1%) and 409,498 (24.2%) satisfied BLS and ALS TOR rules, respectively. One month post-arrest, 2038 (0.2%) and 590 (0.1%) patients in the BLS and ALS cohorts, respectively, achieved favourable neurological outcome. A scoring model derived for the BLS cohort (2 points for age <17 years or ventricular fibrillation/ventricular tachycardia rhythm; 1 point for age <80 years, pulseless electrical activity rhythm, or transport time <25 min) effectively stratified the probability of achieving 1-month favourable neurological outcome, with patients scoring <4 having a probability of <1%, whereas those scoring 4, 5, and 6 having probabilities of 1.1%, 7.1%, and 11.1%, respectively. In the ALS cohort, the probability increased with scores; however, it remained <1%. ConclusionA simple scoring model comprising age, first documented cardiac rhythm, and transport time effectively stratified the likelihood of achieving favourable neurological outcome in patients satisfying the BLS TOR rule.

Impact of defibrillation with automated external defibrillator by bystander before defibrillation by emergency medical system personnel on neurological outcome of out-of-hospital cardiac arrest with non-cardiac etiology

Aim of the studyAlthough defibrillation using automated external defibrillator (AED) by bystander prior to emergency medical system (EMS) arrival was associated with favorable outcomes in out-of-hospital cardiac arrest (OHCA) of cardiac cause, whether it improves outcomes of OHCA due to non-cardiac cause is not clear. We aimed to investigate the impact of defibrillation with AED by bystander before defibrillation by EMS personnel on the outcomes of OHCA of presumed non-cardiac cause. MethodsThis was a retrospective cohort study using the All-Japan Utstein registry (reference period: 2013 to 2017). We included adult patients with OHCA of presumed non-cardiac cause, who had initial shockable rhythm, and who received witnessed arrest bystander cardiopulmonary resuscitation (CPR). Exposure variable was defibrillation with AED by bystander in comparison with initial defibrillation by EMS. Logistic regression analyses were conducted to assess the association between bystander AED shock and favorable neurological outcome (Cerebral Performance Category scale 1 or 2) at one month. ResultsAmong the 1,053 patients included for analysis, 57 (5.4%) received bystander AED shock. There was no statistically significant difference in the rate of favorable neurological outcome at one month between groups [9 (15.8%) vs 109 (10.9%), p = 0.26]. Logistic regression analysis adjusted for characteristics, intervention, and time course of CPR showed no association between bystander AED shock and favorable neurological outcome [OR (95% CI): 1.63 (0.70–3.77), p = 0.25]. ConclusionIn this study, defibrillation with AED by bystander before defibrillation by EMS personnel was not associated with the favorable outcomes of OHCA of presumed non-cardiac cause.

Sex disparities in prehospital advanced cardiac life support in out-of-hospital cardiac arrests in Japan

ObjectiveSex disparities in out-of-hospital cardiac arrest (OHCA) care processes have been reported. This study aimed to investigate the association between sex and prehospital advanced cardiac life support (ACLS) interventions provided by emergency medical services in Japan. MethodsWe analyzed data from January 1, 2013, to December 31, 2020, from the All-Japan Utstein Registry of patients with OHCA aged ≥18 years who were resuscitated by bystanders. The primary outcomes were prehospital ACLS interventions, including advanced airway management (AAM) and epinephrine administration. Sex-based disparities in receiving prehospital ACLS interventions were assessed via multivariable logistic regression analyses. ResultsAmong 314,460 eligible patients, females with OHCA received fewer prehospital ACLS interventions than males: 83,571/187,834 (44.5%) males vs. 55,086/126,626 (43.5%) females (adjusted odds ratio [AOR] = 0.94, 95% confidence interval [CI] = 0.93–0.96) for AAM and 60,097/187,834 (32.0%) males vs. 35,501/126,626 (28.0%) females (AOR = 0.84, 95% CI = 0.83–0.85) for epinephrine administration. Similar results were also obtained in the subgroup analysis (groups included patients aged 18–74 years and ≥75 years and those with cardiac origin, ventricular fibrillation (VF), non-VF, non-family member witnessed, and family member witnessed). ConclusionCompared with males, females were less likely to receive prehospital ACLS. Emergency medical service staff must be made aware of this disparity, and off-the-job training on intravenous cannulation or AAM replacement must be conducted. Investigation of the impact of sex disparity on OHCA care processes can facilitate planning of future public health policies to improve survival outcomes.

Abstract 206: Easily Created Prediction Model Using Deep Learning For Termination Of Resuscitation (tor) In Out Of Hospital Cardiac Arrest (ohca) Cases: The All-japan Utstein Registry Experience.

Background: Correct identification of futile prehospital resuscitation in out-of-hospital cardiac arrest (OHCA) may reduce unnecessary transports. Reliable prediction variables are needed for 'termination of resuscitation' (TOR) rules in OHCA. However, making such prediction models requires a large number of samples and time-consuming statistical analysis. Deep learning (DL), a form of artificial intelligence (AI), is attractive for building such prediction models. We made a TOR prediction model using a DL software, Prediction One (Sony Network Communications Inc., Tokyo, Japan). The purpose of this study was to evaluate the efficacy of this predictive model using general purpose AI compared to the Universal TOR rule for out - of hospital cardiac arrest. Methods: A retrospective, population-based review of OHCA victims without prehospital ROSC from January 1, 2010 to December 31, 2017 in the All-Japan Utstein Registry. We divided half (2010-2014) as a training dataset and half (2015-2017) as an external validation dataset. Prediction one made the prediction model using the training dataset with internal cross-validation. We used both the created model and the Universal TOR rule to predict outcomes using the external validation set. Results: 989,929 OHCA cases, 18 years of age or older, were registered in the All-Japan Utstein Registry and 575,346 cases were of presumed cardiac origin. Of these, 354,356 cases were used as the training dataset and 220,990 cases were used as the external validation dataset. The model made by Prediction One using 11 variables had AUC of 0.969 and F value of 0.969, and its AUC for the validation cohort was 0.964 (95%CI 0.963-0.966) with 99.3% accuracy. The model made by Prediction One using three variables of universal TOR rule had AUC of 0.948 and F value 0.967, and its AUC for the validation cohort was 0.939 (95%CI 0.936-0.942) with 99.1% accuracy. Conclusions: The accuracy of prediction models using Prediction One was good. More research into the utility of using AI for TOR prediction is required.

Abstract 10902: The Association of Public-Access Defibrillation Rate With Mortality and Neurological Outcomes in Out-of-Hospital Cardiac Arrest Patients With Bystander-Witnessed and Initial Shockable Rhythm During Covid-19 Pandemic in Japan

Introduction: On January 16, 2020, the first COVID-19 infectious patient was reported in Japan. Since then, we have faced on the unprecedented COVID-19 pandemic. Initially, the direct mortality caused by COVID-19 had been focused on. However, recently, the pandemic’s indirect negative effects, stagnation of chain of survival, has been seen as a problem. Hypothesis: The negative impact would be particularly large on out-of-hospital cardiac arrest (OHCA) patients with initial shockable rhythm. Methods: This is a retrospective cohort study from the All-Japan Utstein Registry, which is a population-based and nationwide registry. Primary outcome are survival rate and favorable neurological outcome (Cerebral Performance Category of 1 or 2) at 30 days. We identified the association of the use of AED with survival and neurological outcome in patients who had OHCA events, bystander-witnessed and initial shockable rhythm before and after COVID-19 pandemic. Results: We compared the 5,240 OHCA patients with bystander-witnessed and initial shockable rhythm in pandemic period (2020) to the 16,628 of those in non-pandemic period (2017-19). The use of AED was decreased, (22.5 vs 20.3 %, respectively, p&lt;0.001) and the survival rate and the proportion of favorable neurological outcome at 30 days was decreased. (39.3 vs 37.7 %, respectively, p=0.04; 28.7 vs 26.1 %, respectively, p&lt;0.001) In addition, we compared by the regions. In regions of infection spread, the use of AED was decreased (25.9 vs 22.5 %, respectively, p=0.001), and the survival rate and the proportion of favorable neurological outcome at 30 days was decreased. (40.8 vs 36.8%, respectively, p&lt;0.001; 29.5 vs 24.5 %, respectively, p&lt;0.001) However, in regions of infection non-spread, there are no significantly differences in these points. Conclusion: The delay of prehospital intervention may have negatively effected in the survival rate and favorable neurological outcome at 30 days during COVID-19 pandemic.