All-Japan Utstein Registry Research Articles

Abstract 12808: Public Access Defibrillation Has Great Impact on Outcomes After Pediatric Out-of-hospital Cardiac Arrest

Introduction: Use of automated external defibrillators (AEDs) has been recommended for pediatric out-of-hospital cardiac arrest (OHCA). Studies in adults suggest that public-access defibrillation (PAD) improves the outcomes after OHCA, but there have been no conclusive studies in children. Hypothesis: We assessed the hypothesis that PAD is associated with an increased chance of favorable outcomes after pediatric OHCA. Methods: This was a nationwide, population-based, propensity score-matched study of pediatric OHCA in Japan from January 1, 2011, to December 31, 2012, based on data from the All-Japan Utstein Registry. We included pediatric patients who experienced OHCA and received bystander CPR. The primary outcome was a favorable neurological state one month after OHCA defined as a Glasgow-Pittsburgh cerebral performance category (CPC) score of 1-2 (corresponding to a Pediatric CPC score of 1-3). The secondary outcomes included a neurologically favorable survival with a CPC score of 1 (corresponding to a Pediatric CPC score of 1), one-month survival, and prehospital return of spontaneous circulation (ROSC). Results: A total of 1,193 patients were included in the final cohort; 57 received PAD and 1,136 did not. Among 1,193 patients, 188 (15.8%) survived with a favorable neurological status one month after OHCA. The odds of neurologically favorable survival were significantly higher for patients receiving PAD after adjusting for potential confounders: propensity score matching, OR 3.17 (95%CI 1.40-7.17), and multivariable logistic regression modeling, OR 5.10 (95% CI 2.01-13.70). Similar findings were observed for the secondary outcomes. In subgroup analyses, there were no significant differences in neurologically favorable survival between PAD group and no PAD group in unwitnessed cohort (OR 7.76 [0.75-81.90]) and non-cardiac etiology cohort (OR6.65 [0.64-66.24]). Conclusions: In conclusion, PAD was associated with an increased chance of neurologically favorable survival after pediatric OHCA, except for unwitnessed cases and non-cardiac etiology cases.

Abstract 12440: Impact of Changes in the Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care on Neurologically Intact Survival

Introduction: The AHA and International Liaison Committee on Resuscitation (ILCOR) published the Guidelines 2000 for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC). Since 2000, the ILCOR has reported the International Consensus on CPR and ECC Science with Treatment Recommendations (CoSTR) in 5-year cycles. However, few nationwide studies have investigated the efficacy of changes in the CPR guidelines. Methods: A total of 1,136,283 adult patients who received CPR after out-of-hospital cardiac arrest (OHCA) between 2005 and 2014 were included from the All-Japan Utstein Registry, a prospective, nationwide, population-based registry. We divided the study patients into 3 groups according to each guideline era (the G2000 era was cases in 2005, the CoSTR2005 era from 2006 to 2010 and the CoSTR2010 era from 2011 to 2014). The primary endpoint was favorable 30-day neurological outcome after OHCA. Multiple logistic regression analysis for primary endpoint was performed to adjust for possible confounders due to imbalances in baseline characteristics. Results: Of the 1,136,283 patients, 100,509 (8.8%) were in the G2000 era, 549,147 (48.3%) in the CoSTR2005 era and 486,627 (42.8%) in the CoSTR2010 era. Baseline characteristics exhibited significant differences among the three groups, including age, sex, time interval from call receipt to paramedic arrival at patient’s side, arrest witnessed, bystander CPR, initial arrest rhythm, advanced CPR, cause of OHCA, etc. After adjustment for resuscitation, the CoSTR2005 and the CoSTR2010 (reference, the G2000) were independent predictor of favorable 30-day neurological outcome (the CoSTR2005: adjusted OR, 1.588; 95% CI: 1.488-1.696, and the CoSTR2010: adjusted OR, 2.100; 95% CI: 1.966-2.242, respectively) and the subgroups of patients with even unwitnessed OHCA (the CoSTR2005: adjusted OR, 1.210; 95% CI: 1.057-1.386, and the CoSTR2010: adjusted OR, 1.484; 95% CI: 1.296-1.700, respectively). Conclusions: In a nationwide study for all adult patients with OHCA, the CoSTR2005 had favorable neurological outcome 1.6 times as high as the G2000, and also the CoSTR2010 had it 2.2 times. The neurologically intact survival increased each time the CPR guidelines were changed.

Abstract 12806: Advanced Airway Management May Not be Effective Compared to Basic Airway Management After Pediatric Out-of-hospital Cardiac Arrest

Introduction: Respiratory care for pediatric out-of-hospital cardiac arrest (OHCA) may play an important role due to the asphyxial nature of the majority of pediatric OHCA events. Hypothesis: We assessed the hypothesis that prehospital advanced airway management (endotracheal intubation or supraglottic airway device) is associated with an increased chance of favorable outcomes compared with basic airway management (bag-valve-mask ventilation) after pediatric OHCA. Methods: This was a nationwide, population-based, propensity score-matched study of pediatric OHCA in Japan from January 1, 2011, to December 31, 2012, based on data from the All-Japan Utstein Registry. We included pediatric patients aged < 18 years. Infants (≤ 1 year old) were excluded. The primary outcome was a favorable neurological state one month after OHCA defined as a Glasgow-Pittsburgh cerebral performance category (CPC) score of 1-2 (corresponding to a Pediatric CPC score of 1-3). The secondary outcomes included a neurologically favorable survival with a CPC score of 1 (corresponding to a Pediatric CPC score of 1), one-month survival, and prehospital return of spontaneous circulation (ROSC). Results: A total of 2,157 patients were included in the final cohort; 365 received advanced airway management and 1,792 received basic airway management. Among 2,157 patients, 213 (9.9%) survived with a favorable neurological status one month after OHCA. There were no significant differences in neurologically favorable survival between the advanced airway management group and the basic airway management group after adjusting for potential confounders: propensity score matching, OR 0.74 (95%CI 0.35-1.59), and multivariable logistic regression modeling, OR 0.55 (95% CI 0.24-1.14). Similar findings were observed for the secondary outcomes. In subgroup analyses (including the non-cardiac [mainly asphyxial] etiology group), there were no subgroups in which advanced airway management was associated with neurologically favorable survival. Conclusions: In conclusion, advanced airway management was not associated with an increased chance of neurologically favorable survival, one-month survival, or prehospital ROSC compared to basic airway management after pediatric OHCA.

Abstract 12908: Impact of Bystander Cardiopulmonary Resuscitation by Family Members on Return of Spontaneous Circulation and Neurological Prognosis in Patients With Out-of-Hospital Cardiac Arrests: A Nationwide, Population-Based Cohort Study

Introduction: Out-of-hospital cardiac arrests (OHCAs) are critical events and bystander cardiopulmonary resuscitation (byCPR) affects the survival and prognosis of OHCAs. Most byCPR occur in a family setting in Japan. Although there are many reports on the effect of byCPR, there are few considerations about the person who operated byCPR in Japan. Hypothesis: We hypothesized that byCPR by a family member is more effective for return of spontaneous circulation (ROSC) and neurological prognosis against OHCAs of cardiac origin compared to non-family operators without emergency medical services (EMS ). Methods: In All-Japan Utstein Registry of the Fire and Disaster Management Agency, 1,176,363 patients who suffered from OHCAs were enrolled between 2005 and 2014. We selected 162,390 patients who were witnessed, those aged > 18 years and had OHCAs of cardiac origin. We classified the patients by age, gender, initial rhythm, verbal instruction, witness-to-CPR time by EMS, airway management, drug administration in ambulance, and secondary lifesaving treatment by doctor in ambulance. Results: In this study cohort, the byCPR by citizen were included family members (n=137,147), friends (n=9,132), colleagues (n=7,956), and passersby (n=8,155). The incidence of ROSC was 11.6%, 18.8%, 24.7%, and 22.2% among family members, friends, colleagues, and passersby, respectively and was significantly higher in friends (OR: 1.25, 95%CI: 1.18-1.33, p<0.000), colleagues (OR: 1.35, 95%CI: 1.28-1.44, p<0.000), or passersby (OR: 1.46, 95%CI: 1.38-1.55, p<0.000) than family members. In family members, the rates of defibrillation, first aid and chest compression were significantly lower than those in others. The time from witness to byCPR was significantly later in family members than in others. The incidence of ROSC after adjusting above-mentioned factors and the rates of defibrillation was also significantly lower in family members than in others. We also performed same investigation for neurological prognosis, and the results were similar. Conclusions: The incidence of ROSC and neurologically intact survival in byCPR by family members were lower than in others, regardless of the presence of defibrillation. Family members need to have education as bystanders.

Duration of Prehospital Resuscitation Efforts After Out-of-Hospital Cardiac Arrest.

During out-of-hospital cardiac arrest, it is unclear how long prehospital resuscitation efforts should be continued to maximize lives saved. Between 2005 and 2012, we enrolled 282 183 adult patients with bystander-witnessed out-of-hospital cardiac arrest from the All-Japan Utstein Registry. Prehospital resuscitation duration was calculated as the time interval from call receipt to return of spontaneous circulation in cases achieving prehospital return of spontaneous circulation or from call receipt to hospital arrival in cases not achieving prehospital return of spontaneous circulation. In each of 4 groups stratified by initial cardiac arrest rhythm (shockable versus nonshockable) and bystander resuscitation (presence versus absence), we calculated minimum prehospital resuscitation duration, defined as the length of resuscitation efforts in minutes required to achieve ≥99% sensitivity for the primary end point, favorable 30-day neurological outcome after out-of-hospital cardiac arrest. Prehospital resuscitation duration to achieve prehospital return of spontaneous circulation ranged from 1 to 60 minutes. Longer prehospital resuscitation duration reduced the likelihood of favorable neurological outcome (adjusted odds ratio, 0.84; 95% confidence interval, 0.838-0.844). Although the frequency of favorable neurological outcome was significantly different among the 4 groups, ranging from 20.0% (shockable/bystander resuscitation group) to 0.9% (nonshockable/bystander resuscitation group; P<0.001), minimum prehospital resuscitation duration did not differ widely among the 4 groups (40 minutes in the shockable/bystander resuscitation group and the shockable/no bystander resuscitation group, 44 minutes in the nonshockable/bystander resuscitation group, and 45 minutes in the nonshockable/no bystander resuscitation group). On the basis of time intervals from the shockable arrest groups, prehospital resuscitation efforts should be continued for at least 40 minutes in all adults with bystander-witnessed out-of-hospital cardiac arrest. URL: http://www.umin.ac.jp/ctr/. Unique identifier: 000009918.

Utilizing Big Data for Public Health

Big data is usually defined as information assets characterized by such high volume, velocity, and variety that specific technology and analytical methods are required for its transformation into value.1 Analysis of big data may provide useful information in a variety of areas, including healthcare.2 Numbers of data sets obtained from routine operations in the area of healthcare have rapidly increased in recent years, due to cheap and advanced information collection systems, but challenges in extracting useful information from large and complex datasets remain. In this context, an accompanying article published in this issue of the Journal of Epidemiology investigated outcomes after out-of-hospital cardiac arrest using data from the All-Japan Utstein registry for the Fire and Disaster Management Agency, which is a nationwide population-based registry based on guidelines for uniform reporting of cardiac arrest.3 The proportion of patients in the registry with favorable neurological outcomes was 1.6% during the national meetings of the Japanese Society of Intensive Care Medicine, the Japanese Association for Acute Medicine, and the Japanese Circulation Society, while the proportion was 1.5% during the remaining days of the year. Likewise, 1-month survival rates were comparable between meeting days (3.8%) and non-meeting days (3.8%). The present analysis of big data from the nationwide registry of cardiac arrests supports the robustness of the emergency healthcare system in Japan and suggests that the quality of emergency care is maintained even when many professionals in emergency medicine are absent from their hospitals to attend medical conferences. As demonstrated in the accompanying article,3 big data may provide useful information enabling the public sector and healthcare providers to assess their healthcare systems and distribution of resources. Big healthcare data also has great potential to improve our understanding of the effectiveness of treatments in the real world, as well as of the incidence, management, and prognosis of various medical conditions, particularly for rare diseases. Useful information obtained from big data will allow health professionals to provide better medical care. Although the privacy of individuals’ information must be protected, considering the great potential of big data, healthcare data generated within governmental processes should be open to researchers who have unique ideas on providing useful information regarding public health.

Trends in Outcomes for Out-of-Hospital Cardiac Arrest by Age in Japan: An Observational Study.

Population aging has rapidly advanced throughout the world and the elderly accounting for out-of-hospital cardiac arrest (OHCA) has increased yearly.We identified all adults who experienced an out-of-hospital cardiac arrest in the All-Japan Utstein Registry of the Fire and Disaster Management Agency, a prospective, population-based clinical registry, between 2005 and 2010. Using multivariable regression, we examined temporal trends in outcomes for OHCA patients by age, as well as the influence of advanced age on outcomes. The primary outcome was a favorable neurological outcome at 1 month after OHCA.Among 605,505 patients, 454,755 (75.1%) were the elderly (≥65 years), and 154,785 (25.6%) were the oldest old (≥85 years). Although neurological outcomes were worse as the age group was older (P < 0.0001 for trend), there was a significant trend toward improved neurological outcomes during the study period by any age group (P < 0.005 for trend). After adjustment for temporal trends in various confounding variables, neurological outcomes improved yearly in all age groups (18–64 years: adjusted OR per year 1.15 [95% CI 1.13–1.18]; 65–84 years: adjusted OR per year 1.12 [95% CI 1.10–1.15]; and ≥85 years: adjusted OR per year 1.08 [95% CI 1.04–1.13]). Similar trends were found in the secondary outcomes.Although neurological outcomes from OHCA ware worse as the age group was older, the rates of favorable neurological outcomes have substantially improved since 2005 even in the elderly, including the oldest old. Careful consideration may be necessary in limiting treatment on OHCA solely for the reason of advanced age.

Abstract 13624: Effect of Electrical Therapy Using Biphasic Defibrillators in the 2010 CPR Guidelines for Patients With Out-of-Hospital Cardiac Arrest due to Nonshockable Rhythm

Background: The 2005 guidelines for cardiopulmonary resuscitation (CPR) with electrical therapy recommended a single shock plus an immediate 2 minutes of CPR instead of 3-shock sequences recommended in the 2000 guidelines. The 2010 guidelines have stressed that it is necessary to improve CPR quality. Each set of guidelines recommended a timely shock when non-shockable patients were found to be in shockable rhythm. Few data are available concerning this electrical therapy. Methods: From the data of the All-Japan Utstein Registry, a prospective, nationwide, population-based registry of out-of-hospital cardiac arrest (OHCA), we included adult patients who had OHCA due to cardiac etiology, in whom non-shockable arrest were recorded as an initial rhythm, and who received shock using biphasic AEDs after conversion from non-shockable arrest to shockable arrest by emergency medical service (EMS) personnel. Study patients were divided into three groups based on the different CPR guidelines; 3-shock protocol in the 2000 guidelines (2000G), 1-shock protocol in the 2005 guidelines (2005G), and 1-shock protocol in the 2010 guidelines (2010G). The primary endpoint was favorable neurological outcome at 30 days after OHCA. Results: Of the 5066 patients who met the inclusion criteria (figure). The figure shows the comparison of favorable neurological using biphasic AEDs in the three groups. Adjusted odds ratios for favorable neurological outcome were 2.5 (95% CI, 1.3 to 4.7) after the 2005G group and the 2010G group as compared with the 2000G group, and 0.8 (95% CI, 0.6 to 1.1) after the 2010G group as compared with the 2005G group. ConclusioN: The single-shock protocol using biphasic AEDs of the 2005 and 2010 guidelines were superior to the 3-shock protocol of the 2000 guidelines, but the single-shock protocol using biphasic AEDs of the 2005 and 2010 guidelines had similar 30-day favorable neurological outcome in patients with non-shockable cardiac arrest.

The daily incidence of out-of-hospital cardiac arrest unexpectedly increases around New Year's Day in Japan

BackgroundOver 100,000 patients are diagnosed every year as out-of-hospital cardiac arrest (OHCA) cases in Japan and their number has continued to rise for the last decade, presenting a challenge for preventive public health research as well as emergency medical care. The purpose of this study was to identify whether there are any temporal patterns in daily OHCA presentations in Japan. MethodsRecords of OHCA patients (n=701,651) transported by ambulance over the course of six years (1st January 2005 to 10th March 2011) in Japan were obtained from the All-Japan Utstein registry data of cardiopulmonary arrest patients. Time periods within which the incidence of OHCA significantly increased were identified by a temporal cluster detection test using scan statistics. The risk ratios of OHCA for the detected periods were calculated and adjusted according to a Poisson regression model accounting for effects of other factors. ResultsThe risk of OHCA significantly rises 1.3–1.6 times around New Year's Day in Japan. ConclusionsOur analysis revealed the increased daily incidence of OHCA around every New Year's Day in Japan.

Effects of prehospital epinephrine administration on neurological outcomes in patients with out-of-hospital cardiac arrest.

BackgroundTo determine if the effects of epinephrine administration on the outcome of out-of-hospital cardiac arrest (OHCA), patients are associated with the duration of cardiopulmonary resuscitation (CPR) performed by Emergency Medical Service (EMS) personnel.MethodsThis retrospective, nonrandomized, observational analysis used the All-Japan Utstein Registry, a prospective, nationwide population-based registry of all OHCA patients transported to the hospital by EMS staff as the data source. We stratified all OHCA patients for quartile of EMSs’ CPR duration. Group 1 consisted of patients who fell under the 25th percentile of EMSs’ CPR duration (under 15 min); group 2, patients who fell into the 25th to 50th percentile (between 15 and 19 min); group 3, patients who fell into the 50th to 75th percentile (between 20 and 26 min); and group 4, patients who fell at or above the 75th percentile (over 26 min). The primary endpoint was a favorable neurological outcome 1 month after cardiac arrest. The secondary endpoints were ROSC before arrival at the hospital and 1-month survival.ResultsA total of 383,811 patients aged over 18 years who had experienced OHCA between 2006 and 2010 in Japan, when stratified for quartile of EMSs’ CPR duration, the epinephrine administration increased the rate of return of spontaneous circulation (ROSC) approximately tenfold in all groups. However, the beneficial effects of epinephrine administration on 1-month survival disappeared in patients on whom EMSs’ CPR had been performed for more than 26 min, and the beneficial effects of epinephrine administration on neurological outcomes were observed only in patients on whom EMSs’ CPR had been performed between 15 and 19 min (odds ratio, 1.327, 95 % confidence intervals, 1.017–1.733 P = 0.037).ConclusionsEpinephrine administration is associated with an increase of ROSC and with improvement in the neurological outcome on which EMSs’ CPR duration is performed between 15 and 19 min.

Association between the Consumption of Carbonated Beverages and Out-of-Hospital Cardiac Arrests of Cardiac Origin in Japan

Background: The consumption of carbonated beverages has been shown to increase the risk of developing metabolic syndrome. The associations between the consumption of carbonated beverages and left arterial dimension or left ventricular mass are believed to be likely related to the greater body weight of carbonated beverage drinkers relative to non-drinkers. Nonetheless, little is known about the association between the consumption of carbonated beverages and out-of-hospital cardiac arrests (OHCAs) in Japan. Methods: We compared the age-adjusted incidence of OHCAs to the expenditures on various beverages per person between 2005 and 2011 in the 47 prefectures of Japan. Patients who suffered from OHCAs of cardiac and non-cardiac origin were enrolled in All-Japan Utstein Registry of the Fire and Disaster Management Agency. The expenditures on various beverages per person in the 47 prefectures in Japan were obtained from data published by the Ministry of Health, Labour and Welfare of Japan. Results: There were 797,422 cases of OHCA in the All-Japan Utstein registry between 2005 and 2011, including 11,831 cases who did not receive resuscitation. Among these 785,591 cases of OHCA, 435,064 (55.4%) were classified as cardiac origin and 350,527 (44.6%) were non-cardiac origin. Non-cardiac origin included cerebrovascular disease, respiratory disease, malignant tumor, and exogenous disease (4.8%, 6.1%, 3.5%, and 18.9%, respectively). The expenditures on carbonated beverages were significantly associated with OHCAs of cardiac origin (r = 0.30, p = 0.04), but not non-cardiac origin (r = -0.03, p = 0.8). Expenditures on other beverages, including green tea, tea, coffee, cocoa, fruit or vegetable juice, fermented milk beverage, milk beverage, and mineral water, were not significantly associated with OHCAs of cardiac origin. Conclusion: Carbonated beverage consumption was significantly and positively associated with OHCAs of cardiac origin in Japan, indicating that beverage habits might play a role in OHCAs of cardiac origin.

Impact of the Great East Japan earthquake on out-of-hospital cardiac arrest with cardiac origin in non-disaster reas

BackgroundTo examine changes in the incidence of out-of-hospital cardiac arrest (OHCA) with cardiac origin in the non-disaster areas of Japan before and after the Great East Japan Earthquake of 11...

Impact of seasonal temperature environment on the neurologic prognosis of out-of-hospital cardiac arrest: A nationwide, population-based cohort study

ObjectiveThe relationship between environmental factors, such as winter or cold environments, and the onset of out-of-hospital cardiac arrest (OHCA) is well known. However, the association between environmental factors and the neurologic outcome of OHCA is poorly understood. This study aimed to assess the impact of the ambient temperature on the neurologic outcome of adult OHCA. MethodsIn a nationwide, population-based, observational study, we enrolled 121 081 adults 18 years or older who experienced an OHCA from January 1, 2010, to December 31, 2010. We used the All-Japan Utstein Registry database coupled with climate statistics data from the Japan Meteorological Agency. The primary end point was favorable neurologic outcome 1 month after OHCA. ResultsOf the eligible 120 721 adult patients with OHCA, 7747 cases of OHCA (6.4%) occurred during the cold season, 80 739 (66.9%) occurred during the midseason, and 32 235 (26.7%) occurred during the warm season. The adults who experienced an OHCA during the cold season exhibited a significantly lower rate of a favorable neurologic outcome than did those who experienced an OHCA during the warm season (2.4% vs 3.3%; odds ratio, 0.73; 95% confidence interval, 0.62-0.85; P < .0001). The adjusted odds ratio for favorable neurologic outcome per 1°C increase in the monthly ambient temperature was 1.006 (95% confidence interval, 1.002-1.010; P = .0080). ConclusionsThe seasonal ambient temperature is likely to affect favorable neurologic outcome. A lower seasonal ambient temperature may exacerbate the neurologic outcome of OHCA.

Most Important Outcomes Research Papers on Cardiac Arrest and Cardiopulmonary Resuscitation

Cardiac arrest is a common and treatable cause of death and disability. Each year ≈424 000 people experience emergency medical services (EMS)-assessed out-of-hospital cardiac arrest (OHCA) in the United States.1 The actual burden of OHCA is likely significantly higher because a substantial number go unassessed. In a prospective analysis of deaths in a US county, 5.6% of annual mortality was attributable to cardiac arrest.2 Many patients who suffer OHCA do not receive prompt cardiopulmonary resuscitation (CPR). Among those who receive CPR, a large number do not survive because of an inability to restore spontaneous circulation, or anoxic cerebral injury even after restoration of circulation. Nevertheless, when timely interventions are provided, a small proportion of patients (10.4% of all EMS-treated OHCA) recover to resume normal lives. The key therapeutic interventions that make the difference between life and death, metaphorically characterized as the 5 links in a chain of survival by the American Heart Association, include: (1) immediate recognition of cardiac arrest and activation of the EMS, (2) early CPR with emphasis on chest compression, (3) rapid defibrillation, (4) effective advanced life support, and (5) integrated postcardiac arrest care.3 Resuscitation science has undergone major advances since the origins of modern CPR >50 years ago.4 The field continues to be dynamic with emergence of new therapies such as therapeutic hypothermia5 and improvements in systems of care. However, many questions remain on issues such as optimum compression rate, efficacy of chest compression only CPR (CCCPR), dispatcher-assisted CPR, and benefits of postresuscitation measures such as hypothermia. A critical challenge also lies in the translation of resuscitation science into practice. To improve outcomes, each of the links in the chain of survival needs to be executed promptly and effectively. There remain several lacunae, which need to be overcome to develop an …

Abstract 361: Time Interval From Collapse to Return of Spontaneous Circulation and Neurologically Intact Survival for Out-of-Hospital Shockable (Ventricular Fibrillation or Pulseless Ventricular Tachycardia) Cardiac Arrest

Background: Early achievement of return of spontaneous circulation (ROSC) after cardiac arrest is critical to neurologically intact survival, but few data are available concerning this interval for shockable cardiac arrest (ventricular fibrillation or pulseless ventricular tachycardia). Methods: From the All-Japan Utstein Registry, a prospective, nationwide, population-based registry of out-of-hospital cardiac arrest (OHCA) between 2005 and 2011, we included adult patients who received resuscitation care after witnessed OHCA due to shockable arrest, whose ROSC was achieved before hospital arrival and who received post cardiac arrest care after hospital arrival. We evaluated the relationship between the collapse-to-ROSC interval and favorable neurological outcome 30 days after cardiac arrest. Results: Of the 31,845 patients who achieved ROSC after witnessed OHCA, 11,621 (36.5%) achieved ROSC after shockable cardiac arrest. Of these, 54.5% (6,187/11,621) had a 30-day favorable neurological outcome. The favorable group had a significantly shorter collapse-to-ROSC interval compared to the unfavorable group (13.5±8.2 vs. 19.2±10.7 minutes, p&lt;0.0001). After adjustment for resuscitation, the likelihood of favorable neurological outcome decreased for every 1 minute increment in the collapse-to-ROSC interval (adjusted OR; 0.94, 95% CI, 0.93 to 0.94). Non-linear regression analysis showed that frequency of favorable neurological outcome decreased from 76.4% to 0% for every minute that passed between collapse and ROSC. For favorable neurological outcome, a collapse-to-ROSC interval of 57.5 minute had a sensitivity of 100% with a negative predictive value of 99.8%. Furthermore, a collapse-to-ROSC interval with a sensitivity of 100% for favorable neurological outcome was 55.5 minutes in patients receiving bystander CPR, and 58.5 minutes in patients not receiving bystander CPR. Conclusion: Resuscitation efforts to achieve ROSC, contributing to neurologically intact survival, are needed for about 60 minutes for patients with witnessed out-of-hospital shockable cardiac arrest irrespective of bystander CPR attempt.

Abstract 277: Neurologically Intact Survival and Time Interval From Collapse to Return of Spontaneous Circulation for Out-of-Hospital Non-Shockable Cardiac Arrest; A Comparison of Pulseless Electrical Activity and Asystole

Background: Early achievement of return of spontaneous circulation (ROSC) after cardiac arrest is critical to neurologically intact survival, but few data are available concerning this interval comparing pulseless electrical activity (PEA) and asystole. Methods: From the All-Japan Utstein Registry, a prospective, nationwide, population-based registry of out-of-hospital cardiac arrest (OHCA) between 2005 and 2011, we included adult patients who received resuscitation care after witnessed OHCA due to non-shockable arrest and whose ROSC was achieved before hospital arrival. We divided study patients into two groups according to the initial cardiac arrest rhythm and evaluated the relationship between the collapse-to-ROSC interval and favorable neurological outcome 30 days after cardiac arrest. Results: Of the 31,845 patients who achieved ROSC after witnessed OHCA, 12,905 (40.8%) achieved ROSC after PEA and 7,259 (22.8%) after asystole. The PEA group had a significantly shorter collapse-to-ROSC interval compared with the asystole group (18.9±11.6 vs. 25.3±12.6 minutes, p&lt;0.0001) and a significantly higher frequency of 30-day favorable neurological outcome (15.5% vs. 7.1%, p&lt;0.0001). After adjustment for resuscitation, the likelihood of favorable neurological outcome decreased for every 1 minute increment in the collapse-to-ROSC interval in the PEA group (adjusted OR; 0.94, 95% CI, 0.93 to 0.95) and in the asystole group (adjusted OR; 0.93, 95% CI, 0.91 to 0.94). Non-linear regression analysis showed that frequency of favorable neurological outcome decreased from 33.6% to 0% for every minute that passed between collapse and ROSC in the PEA group and from 29.2% to 0% in the asystole group. For favorable neurological outcome, a collapse-to-ROSC interval of 56.5 minutes had a sensitivity of 100% with a negative predictive value of 99.6% in the PEA group, and that of 56.5 minutes had a sensitivity of 100% with a negative predictive value of 99.1% in the asystole group. Conclusion: In patients achieving ROSC after witnessed OHCA, PEA patients had a significantly higher favorable neurological outcome than asystole patients. However, the interval in which resuscitation efforts must be sustained is similar for both arrest rhythms.

Abstract 97: Analysis of Emergency Medical Service-initiated CPR Effectiveness in Out-of Hospital Cardiac Arrest (OHCA) Cases Without Bystander-CPR: From all-Japan OHCA Utstein Registry

Backgrounds: Bystander cardiopulmonary resuscitation (CPR) is essential for good neurological survival (GNS) in out-of-hospital cardiac arrest (OHCA). However previous reports from the All-Japan prospective, population-based OHCA Utstein registry of the Fire and Disaster Management Agency(J-OHCAUR) revealed that around 50% of OHCA did not receive bystander-initiated CPR and treated by the emergency medical service (EMS). The present study examined relationship among the time interval from the witnessed cardiac arrest to EMS-initiated CPR and shock, and GNS one month after the event. Methods and Results: From January 2005 through December 2011, we identified 140,363 witnessed OHCA cases from the J-OHCAUR. Among them, 74,541 cases (53.1%) did not receive bystander-CPR, and 14,911 cases had the initial rhythm of VF or VT. These EMS-initiated CPR cases were classified according to the time-interval from cardiac arrest to CPR and shock; 1,106 in the time-interval of 0 minute (shock first approach), 2.707 in 1 minute, 4.131 in 2 minutes, 2,304 in 3 minutes, 985 in 4 minutes, and 1,047 in 5 to 10 minutes. Rate of GNR (cerebral performance category scale 1 or 2) in each time-intervals were shown in the figure. Effectiveness of CPR was clearly time-dependent, and the earlier shock brought about the better GNS in any time-intervals. Conclusion: Even in OHCA cases without bystander-CPR, time-dependent effectiveness of EMS-initiated CPR and importance of the earlier shock were documented.

Relationship between neurologically intact survival and time interval from collapse to return of spontaneous circulation in patients with out-of-hospital cardiac arrest

Background: Early achievement of Return Of Spontaneous Circulation (ROSC) after cardiac arrest is critical to neurologically intact survival, but few data are available comparing this factor in various cardiac arrest rhythms. Methods: From the All-Japan Utstein Registry between 2005 and 2010, 12,566 adult viticums who had bystander-witnessed out-of-hospital cardiac arrest due to cardiac etiology, whose arrest rhythm was confirmed by emergency medical service responders on arrival at the scene and whose ROSC was identified on arrival at the hospital were included; 7,282 (58%) had ROSC from shockable arrest, 3,140 (25%) from pulseless electrical activity (PEA) and 2,134 (17%) from asystole. The study endpoint was favorable neurological outcome 30 days after cardiac arrest. Results: Among the three arrest groups, significant differences were seen in the collapse-to-ROSC interval (median; 16 minutes in the shockable arrest group, 20 minutes in the PEA group, 26 minutes in the asystole group, p<0.001) and in frequency of 30-day favorable neurological outcome (52.8% in the shockable arrest group, 13.3% in the PEA group, 4.1% in the asystole group, p<0.001). Likelihood of favorable neurological outcome decreased in each group for every 1 minute increment in the collapse-to-ROSC interval (adjusted OR; 0.93 in the shockable arrest group and PEA group, and 0.91 in the asystole group). For every minute that passes between collapse and ROSC, frequency of favorable neurological outcome decreased from 90% to 0% over a 60 minute period in the shockable arrest group, from 50% to 0% over a 50 minute period in the PEA group, and from 40% to 0% over a 40 minute period in the asystole group. Conclusion: Collapse-to-ROSC interval for the attainment of neurologically intact survival differed among cardiac arrest rhythms. The marginal collapse-to-ROSC interval was 60 minutes in shockable arrest, 50 minutes in PEA and 40 minutes in asystole.

The effect of 1-shock protocol using biphasic defibrillators for electrical therapies after out-of-hospital cardiac arrest due to ventricular fibrillation

Background: In recent guidelines for electrical therapy of Cardiopulmonary Resuscitation (CPR), there was insufficient evidence to recommend any specific biphasic waveform. When defibrillation is required, a single shock should be provided with immediate resumption of chest compressions after the shock (1-shock protocol). We investigated the effect of 1-shock protocol using biphasic defibrillators. Methods: From the data of the All-Japan Utstein Registry, a prospective, nationwide, population-based registry of out-of-hospital cardiac arrest, we extracted the patients who were persons 18 years of age or older with bystander-witnessed shockable cardiac arrest due to cardiac etiology in the years 2005 (the 3-shock protocol era), and 2008, 2009 and 2010 (the 1-shock protocol era). The study patients were divided into 4 groups according to the two shock protocols and the two AED waveforms. The primary endpoint was 30-day favorable neurological outcome after cardiac arrest. Results: Of the 17,199 patients who met the inclusion criteria, 7,539 received CPR by bystanders (CPR group), and 9,580 did not receive CPR by bystanders (No CPR group). Figure showed comparisons of favorable neurological outcome between the 1-shock protocol and the 3-shock protocol groups, and between the biphasic AEDs and the monophasic AEDs groups in both groups. Adjusted odds ratios for favorable neurological outcome were 2.5 (95% CI, 2.2 to 2.8) after 1-shock protocol and 1.3 (95% CI, 1.2 to 1.4) after biphasic AEDs in CPR group, and were 2.5 (95% CI, 2.2 to 2.8) after 1-shock protocol and 1.3 (95% CI, 1.2 to 1.4) after biphasic AEDs in No CPR group. ![Figure][1] Figure 1 Conclusion: Single-shock protocol using biphasic AEDs was superior to the others in terms of neurological benefits. [1]: pending:yes

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

ObjectiveThere 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. MethodsWe 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. ResultsIn 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). ConclusionIn 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.