Emergency Medical Services Arrival Research Articles

36 The Safety and Efficacy of Nitroglycerin Use by Paramedics for Treatment of ST Elevation Myocardial Infarction

Nitroglycerin (NTG) is widely used by emergency medical services (EMS) for treatment of cardiac chest pain. Concern for precipitating hypotension in patients with inferior ST elevation myocardial infarction (STEMI) involving the right ventricle and in those with non-cardiac conditions has led some EMS systems to discontinue its use. The objectives of this study were to quantify the risk of hypotension and the benefits of pain relief in patients treated with out-of-hospital NTG for suspected STEMI. Consecutive adult patients with suspected STEMI transported by EMS to one of three participating PCI-capable hospitals were prospectively identified and maintained in a log during an 18-month study period. Investigators reviewed out-of-hospital and hospital records for initial field and emergency department (ED) vital signs, field NTG treatment, and hospital management and outcomes. A second investigator independently confirmed key data and inter-rater reliability, using the kappa statistic, was assessed on a random 10% sample of records. Patients with contraindications to NTG were excluded, including hypotension on EMS arrival and phosphodiesterase 5 inhibitor use within 48 hours. The frequency of ED hypotension, defined as a triage systolic blood pressure (SBP) less than 100mmHg, and the change in pain score were calculated in patients who received field NTG and compared to those who did not. The minimum clinically important difference (MCID) in pain score was set a priori at 1.39. Planned subgroup analyses were patients with final diagnosis of STEMI and percutaneous coronary intervention (PCI) of a mid or proximal right coronary artery (RCA) lesion. The frequency of hypotension was compared with the Cochran-Mantel-Haenszel test and change in SBP and pain score with Hodges-Lehmann’s median difference. Of 940 EMS transports for suspected STEMI, 160 were excluded for initial hypotension; thus 780 comprised the study cohort. Median age was 67 with 61% male. NTG was given to 340 (44%) patients, of whom 32 (9%) had ED hypotension compared with 54 (12%) who did not receive NTG, with a relative risk (RR) of 0.97 (95% CI 0.92, 1.02). Inter-rater reliability was excellent, kappa 0.93 (95% CI 0.80, 1.0). The average decrease in SBP was 17.4±90 mmHg and 6.9±29 mmHg in patients treated with and without NTG respectively, median difference -6 mmHg (95% CI -3, -9). The average change in pain scores for patients treated with and without NTG was -2.2±3.4 and 0±2.0 respectively, median difference -1.5 (95% CI -1.0, -2.0). Of 193 patients with confirmed STEMI, 155 (80%) received NTG. In this subgroup, ED hypotension occurred in 14 (9%) treated with NTG compared to 4 (11%) without NTG and the average pain score was -2.0±3.7 with NTG versus no change without. Finally, among patients with mid or proximal RCA lesions, 60 (80%) received NTG; there was no difference in hypotension with or without field NTG, 4/60 (7%) and 1/15 (7%) respectively. Compared to patients treated with PCI in any other location, the frequency of hypotension after NTG among patients with RCA lesions was similar, RR 0.95 (95% CI 0.87, 1.06). In this cohort of suspected or confirmed STEMI patients, field NTG resulted in pain reduction and was not associated with an increased frequency of ED hypotension, even among those with mid or proximal RCA lesions.

Pediatric survivors of out-of-hospital ventricular fibrillation: Etiologies and outcomes

In general, the prognosis is poor for pediatric patients who experience out-of-hospital (OOH) cardiac arrest, with survival rates of 12% to 29%. The purpose of this study was to describe the causes and outcomes of pediatric patients with documented ventricular fibrillation (VF) at resuscitation from OOH cardiac arrest with sustained return of spontaneous circulation after defibrillation and survival to hospital admission. Retrospective analysis of OOH-VF patients <19 years of age evaluated between 2004 and 2016 was performed. Primary outcome measures included demographics, arrest and resuscitation parameters, cardiac diagnoses, survival, and neurologic outcome. Forty-five patients fulfilled study criteria (median age 12 years; range 2 months to 18 years). Cardiac arrest occurred in public in 68% of cases, with bystander cardiopulmonary resuscitation in 42% before arrival of emergency medical services. All patients underwent defibrillation (1-6 shocks) with return of spontaneous circulation and survival to hospital admission. Underlying etiologies were primary electrical disease (33%), cardiomyopathy (27%), congenital heart disease (11%), other (13%), and unknown (16%). Before arrest, 40% of patients had a cardiac diagnosis and 26% had symptoms. Ultimately, 40 of 45 patients (89%) survived resuscitation to hospital discharge. During 72 ± 37 months of follow-up, 38% of survivors had a normal neurologic outcome, whereas 32% had mild neurologic impairment and 30% had moderate-to-severe neurologic impairment. In pediatric patients resuscitated from OOH-VF, a cardiovascular cause was identified in >80%. Regardless of cause, survival and neurologic prognosis appear improved compared to patients with asystole or pulseless electrical activity. These findings support early rhythm assessment and advanced cardiopulmonary resuscitation protocols in pediatric cardiac arrest victims.

Bystander interventions for out-of-hospital cardiac arrests: substantiated critical components of the chain of survival

Early bystander cardiopulmonary resuscitation (CPR) and defibrillation are both vital components in the chain of survival following out-of-hospital cardiac arrest (OHCA) (1,2). Fortunately, bystander CPR rates in industrialized countries have recently increased from 30% to 50% (3-8). A Swedish analysis reported that CPR performed prior to emergency medical services (EMS) arrival was associated with a 30-day survival rate following OHCA more than twice as high as that associated with no CPR before EMS arrival (5). Further, bystander interventions (bystander CPR and defibrillation) were also associated with an increased likelihood of 1-month neurologically intact survival following OHCA according to an analysis of a Japanese nationwide registry (7). As neurological assessments fluctuate for at least 90 days following cardiac arrest, the American Heart Association (AHA) has recommended that longer-term end points (i.e., 90 days) coupled with neurocognitive and quality-of-life assessments should be considered (9). The AHA further suggests that researchers utilize either Cerebral Performance Categories or modified Rankin Scale for global outcomes of neurological assessment in patients following cardiac arrest (9). However, little is known regarding the impact of bystander intervention on long-term (i.e., >90 days following OHCA) neurologically intact survival (3,10).

Telephone cardiopulmonary resuscitation is independently associated with improved survival and improved functional outcome after out-of-hospital cardiac arrest

Aim of studyThis study aims to quantify the relative impact of Dispatcher-Initiated Telephone cardiopulmonary resuscitation (TCPR) on survival and survival with favorable functional outcome after out-of-hospital cardiac arrest (OHCA) in a population of patients served by multiple emergency dispatch centers and more than 130 emergency medical services (EMS) agencies. MethodsWe conducted a retrospective, observational study of EMS-treated adult (≥18 years) patients with OHCA of presumed cardiac origin in Arizona, between January 1, 2011, and December 31, 2014. We compared survival and functional outcome among three distinct groups of OHCA patients: those who received no CPR before EMS arrival (no CPR group); those who received BCPR before EMS arrival and prior to or without telephone CPR instructions (BCPR group); and those who received TCPR (TCPR group). ResultsIn this study, 2310 of 4391 patients met the study criteria (median age, 62 years; IQR 50, 74; 1540 male). 32.8% received no CPR, 23.8% received Bystander-Initiated CPR and 43.4% received TCPR. Overall survival was 11.5%. Using no CPR as the reference group, the multivariate adjusted odds ratio for survival at hospital discharge was 1.51 (95% confidence interval [CI], 1.04, 2.18) for BCPR and 1.64 (95% CI, 1.16, 2.30) for TCPR. The multivariate adjusted odds ratio of favorable functional outcome at discharge was 1.58 (95% CI 1.05, 2.39) for BCPR and 1.56 (95% CI, 1.06, 2.31) for TCPR. ConclusionTCPR is independently associated with improved survival and improved functional outcome after OHCA.

Multiple Naloxone Administrations Among Emergency Medical Service Providers is Increasing

Background: Opioid overdoses are at epidemic levels in the United States. Emergency Medical Service (EMS) providers may administer naloxone to restore patient breathing and prevent respiratory arrest. There was a need for contemporary data to examine the number of naloxone administrations in an EMS encounter. Methods: Using data from the National Emergency Medical Services Information System, we examined data from 2012–5 to determine trends in patients receiving multiple naloxone administrations (MNAs). Logistic regression including demographic, clinical, and operational information was used to examine factors associated with MNA. Results: Among all events where naloxone was administered only 16.7% of the 911 calls specifically identified the medical emergency as a drug ingestion or poisoning event. The percentage of patients receiving MNA increased from 14.5% in 2012 to 18.2% in 2015, which represents a 26% increase in MNA in 4 years. Patients aged 20–29 had the highest percentage of MNA (21.1%). Patients in the Northeast and the Midwest had the highest relative MNA (Chi Squared = 539.5, p < 0.01 and Chi Squared = 351.2, p < 0.01, respectively). The logistic regression model showed that the adjusted odds ratios (aOR) for MNA were greatest among people who live in the Northeast (aOR = 1.18, 95% CI = 1.13–1.22) and for men (aOR = 1.13, 95% CI = 1.10–1.16), but lower for suburban and rural areas (aOR = 0.76, 95% CI = 0.72–0.80 and aOR = 0.85, 95% CI = 0.80–0.89) and lowest for wilderness areas (aOR = 0.76, 95% CI = 0.68–0.84). Higher adjusted odds of MNA occurred when an advanced life support (ALS 2) level of service was provided compared to basic life support (BLS) ambulances (aOR = 2.15, 95% CI = 1.45–3.16) and when the dispatch complaint indicated there was a drug poisoning event (aOR = 1.12, 95% CI = 1.09–1.16). Reported layperson naloxone administration prior to EMS arrival was rare (1%). Conclusion: This study shows that frequency of MNA is growing over time and is regionally dependent. MNA may be a barometer of the potency of the opioid involved in the overdose. The increase in MNA provides support for a dosage review. Better identification of opioid related events in the dispatch system could lead to a better match of services with patient needs.

Hypothermia in trauma victims at first arrival of ambulance personnel: an observational study with assessment of risk factors

BackgroundHypothermia is common in trauma victims and is associated with increased mortality, however its causes are little known. The objective of this study was to identify the risk factors associated with hypothermia in prehospital management of trauma victims.MethodsThis was an ancillary analysis of data recorded in the HypoTraum study, a prospective multicenter study conducted by the emergency medical services (EMS) of 8 hospitals in France. Inclusion criteria were: trauma victim, age over 18 years, and victim receiving prehospital care from an EMS team and transported to hospital by the EMS team in a medically equipped mobile intensive care unit. The following data were recorded: victim demographics, circumstances of the trauma, environmental factors, patient presentation, clinical data and time from accident to EMS arrival. Independent risk factors for hypothermia were analyzed in a multivariate logistic regression model.ResultsA total of 461 trauma patients were included in the study. Road traffic accidents (N = 261; 57%) and falls (N = 65; 14%) were the main causes of trauma. Hypothermia (<35 °C) was present in 136/461 cases (29%). Independent factors significantly associated with the presence of hypothermia were: a low GCS (Odds Ratio (OR) = 0,87 ([0,81-0,92]; p < 0.0001), a low air temperature (OR = 0,93 [0,91-0,96]; p < 0.0001) and a wet patient (OR = 2,08 [1,08-4,00]; p = 0.03).ConclusionThe incidence of hypothermia was high on EMS arrival at the scene. Body temperature measurement and immediate thermal protection should be routine, and special attention should be given to patients who are wet.Level of evidenceProspective, multicenter, open, observational study; Level IV.

Mortality after out-of-hospital cardiac arrest in a Spanish Region.

AimsTo determine out-of-hospital cardiac arrest mortality in the province of Alicante (Spain) and its associated factors.MethodsCross-sectional observational study of all patients who received cardiopulmonary resuscitation (CPR) by the Emergency Medical Services (EMS) (n = 422) in the province of Alicante in 2013. To determine associated factors, a binary logistic regression model was constructed. Primary outcome: death before arriving at the hospital. Predictive variables: gender, age, artificial respiration, prior functional status, asystole, cardiogenic aetiology, bystander CPR, time from the cardiac arrest to the arrival of the EMS and location of cardiac arrest.ResultsThere were 337 deaths (79.9%; 95% CI: 76.0–83.7%). Factors independently associated (p<0.05) with death were: male gender (OR = 2.11; 95% CI: 1.20–3.72; p = 0.010), asystole (OR = 1.99, 95% CI: 1.17–3.39; p = 0.012), cardiac arrest at home (OR = 2.44; 95% CI: 1.42–4.18; p = 0.001) and an increased time between arrest and EMS arrival (OR = 1.05, 95% CI: 1.01–1.09, p = 0.009). Having a worse prior functional status had a tendency towards significance (OR = 0.56, 95% CI: 0.31–1.02, p = 0.059).ConclusionsMortality was high. The associated factors were: male gender, asystole, worse prior functional status, longer time from the cardiac arrest to the arrival of the EMS and having the cardiac arrest at home. The clearly negative impact of experiencing a cardiac arrest at home necessitates modifying training policies in Spain. These policies should be focused on providing information about CPR in schools in order to decrease the mortality of these events.

New signs to encourage the use of Automated External Defibrillators by the lay public

IntroductionPublic Access Defibrillation – the use of Automated External Defibrillators (AEDs) by lay bystanders before the arrival of Emergency Medical Services – is an important strategy in delivering prompt defibrillation to victims of out-of-hospital cardiac arrest and can greatly improve survival rates. Such public-access AEDs are used rarely: one barrier might be poor understanding and content of current signage to indicate their presence. The aim of this project was to develop a sign, with public consultation, that better indicated the function of an AED, and an associated poster to encourage its use. MethodsTwo public surveys were undertaken, in July and December 2015, to investigate perceptions of the current AED location sign recommended for use in the UK and to produce an improved location sign and associated information poster. ResultsThere were 1895 and 2115 respondents to the surveys. Fewer than half (47.9%, 895/1870) understood what the current location sign indicated. One of four design options for a location sign best explained the indication for (preferred by 56.0%, 1023/1828) and best encouraged the use of a public AED (51.8%, 946/1828). 83.5% (1766/2115) preferred an illustration of a stylised heart trace to the lightning bolt used at present. From five wording options, ‘Defibrillator – Heart Restarter’ was the most popular (29.4%, 622/2115). An associated poster was developed using design features from the new location sign, findings from the surveys and expert group input regarding its content. ConclusionsThis is the first time that public consultation has been used to design a public AED location sign. Effective signage has the potential to help break down the barriers to more widespread use of AEDs in public places.

Abstract 22: Geographic Proximity of Automated External Defibrillators to Out-of-hospital Sudden Deaths in Wake County, North Carolina

Introduction: Survival rates for out-of-hospital sudden cardiac arrest are substantially improved by access to automated external defibrillators (AEDs) prior to Emergency Medical Services (EMS) arrival. However, AED use may be inhibited if their locations are unknown or far from the bystander. Objectives: We sought to classify out-of-hospital sudden death (OHSD) event locations, ascertain if bystanders utilized AEDs prior to EMS arrival, and calculate the distance to the nearest AED. Methods: From 2013 to 2015, we screened all EMS-reported out-of-hospital deaths aged 18-64 within Wake County, North Carolina to identify OHSDs. We geocoded event locations from EMS records and classified them as residential, commercial, public, or unknown using US Postal Service Residential Delivery Indicator, EMS narratives, and web searches. AED locations and installation dates, registered by law, were obtained from North Carolina Department of Health and Human Services. We used EMS narratives to determine AED use prior to EMS arrival. Walking distance between coordinates of an OHSD location and every AED installed prior to the death date was estimated using the Great-Circle distance. Results: Of 434 adjudicated OHSDs, 390 (90%) were residential, 31 (7%) were commercial, and 11 (2.5%) were public. Of commercial locations, 12 (39%) occurred in hotels. Of public locations, 6(46%) occurred in parking lots or parks. Wake County had 168 registered AEDs during the study period. The mean distance from OHSD to closest AED was 3.2 km (95% CI: 3.0-3.5 km). Only 20 (4.6%) of OHSDs were within 500 meters of an AED; the closest AED was 77 meters from an OHSD. Bystanders used AEDs prior to EMS arrival twice. Conclusions: While potentially lifesaving, AEDs are not placed optimally with respect to OHSD locations and are rarely utilized by bystanders, even in non-residential spaces. Public health strategies should be considered that incentivize optimal AED placement to witnessed cardiac arrest locations.

Public health surveillance of automated external defibrillators in the USA: protocol for the dynamic automated external defibrillator registry study

IntroductionLay use of automated external defibrillators (AEDs) before the arrival of emergency medical services (EMS) providers on scene increases survival after out-of-hospital cardiac arrest (OHCA). AEDs have been placed in...

A Descriptive Analysis of Tactical Casualty Care Interventions Performed by Law Enforcement Personnel in the State of Wisconsin, 2010-2015.

This was a descriptive analysis of a convenience sample of cases submitted to the Wisconsin Tactical Medicine Initiative (Wisconsin USA), after the provision of successful patient care, between January 2010 and December 2015. The study was reviewed by the Mayo Foundation Institutional Review Board (Rochester, Minnesota USA) and deemed exempt. Nineteen agencies submitted information during the study period. Of the 56 episodes of care reported, four (7.1%) cases involved care provided to injured officers while 52 (92.9%) involved care to injured civilians, including suspects. In at least two cases, on-going threats existed during the provision of medical care to an injured civilian. Law enforcement rendered care prior to Emergency Medical Services (EMS) arrival in all but two cases. The current case series demonstrates the life-saving potential for law enforcement personnel trained and equipped under current Tactical Combat Casualty Care (TCCC)/ Committee on Tactical Emergency Casualty Care (C-TECC) tactical casualty care guidelines. Although originally developed to save the lives of wounded combat personnel, in the civilian sector, the training appears more likely to save victims rather than law enforcement personnel. Stiles CM , Cook C , Sztajnkrycer MD . A descriptive analysis of tactical casualty care interventions performed by law enforcement personnel in the State of Wisconsin, 2010-2015. Prehosp Disaster Med. 2017;32(3):284-288.

Defibrillation before EMS arrival in western Sweden

BackgroundBystanders play a vital role in public access defibrillation (PAD) in out-of-hospital cardiac arrest (OHCA). Dual dispatch of first responders (FR) alongside emergency medical services (EMS) can reduce time to first defibrillation. The aim of this study was to describe the use of automated external defibrillators (AEDs) in OHCAs before EMS arrival. MethodsAll OHCA cases with a shockable rhythm in which an AED was used prior to the arrival of EMS between 2008 and 2015 in western Sweden were eligible for inclusion. Data from the Swedish Register for Cardiopulmonary Resuscitation (SRCR) were used for analysis, on-site bystander and FR defibrillation were compared with EMS defibrillation in the final analysis. ResultsOf the reported 6675 cases, 24% suffered ventricular fibrillation (VF), 162 patients (15%) of all VF cases were defibrillated before EMS arrival, 46% with a public AED on site. The proportion of cases defibrillated before EMS arrival increased from 5% in 2008 to 20% in 2015 (p<0.001). During this period, 30-day survival increased in patients with VF from 22% to 28% (p=0.04) and was highest when an AED was used on site (68%), with a median delay of 6.5min from collapse to defibrillation. Adjusted odds ratio for on-site defibrillation versus dispatched defibrillation for 30-day survival was 2.45 (95% CI: 1.02–5.95). ConclusionsThe use of AEDs before the arrival of EMS increased over time. This was associated with an increased 30-day survival among patients with VF. Thirty-day survival was highest when an AED was used on site before EMS arrival.

Abstract WP250: Transport Times and Door to Needle Times for Stroke Patients Transported by EMS

Background: Treatment of acute ischemic stroke with intravenous thrombolytics (IV tPA) within the therapeutic window is more likely achieved when there is rapid activation of emergency medical services (EMS), identification of stroke, direct transport to Acute Stroke-Ready Hospitals, and expedited ED evaluation. Objective: To characterize the relation between EMS treatment interval and door to needle times in a regional stroke system of care. Methods: This is a retrospective analysis of consecutive patients with positive prehospital stroke screens transported to an approved stroke center in a large metropolitan system from January 2011 to December 2014. Data, including EMS on scene time, ED arrival time, and time of IV tPA administration, was abstracted from the regional EMS Agency stroke database. The median times from EMS arrival on scene to ED arrival (scene to door) and from ED arrival to IV tPA (door to needle) were calculated along with the total scene to needle time. The correlation coefficient was calculated between scene to door and door to needle time. Results: Among 16,317 patients transported for suspected stroke, the median age was 75 (Interquartile range [IQR] 62-85) years, 53% were women, 66% White, 11% Asian, 10% Black and 24% Hispanic. 84% had a cerebrovascular final diagnosis, ischemic stroke (IS) being the most common (n=8606, 53%). 16% had a non-stroke-related diagnosis. The median NIHSS was 9 (IQR 4 to 19). Median scene to door time was 29mins (IQR 23-38). IV tPA was administered to 1655 patients (19% with final diagnosis of IS), with 84% treated within 3hrs of LWKT (median=128mins, IQR 99-165). Among patients receiving IV tPA, the median scene to door time was 28mins (IQR 22-36), door to needle time 92mins (IQR 68-98) and scene to needle time 116mins (IQR 89-126). There was no correlation between scene to door and door to needle time (r=-0.0014). Conclusions: In this large metropolitan region, scene to door times for stroke transports averaged just under 30mins and scene to needle times just under 2hrs. There was no correlation between scene to door and door to needle times. These findings provide data to guide efforts to reduce first responder to final treatment intervals throughout regional EMS stroke systems.

Abstract WP258: Simulating the Impact of Direct Transport of Patients with Suspected Large Vessel Occlusion to Comprehensive Stroke Centers in a Large Urban Emergency Medical Services System

Introduction: One strategy to facilitate timely endovascular revascularization therapy (ERT) is for emergency medical services (EMS) to transport patients with suspected acute ischemic stroke from large vessel occlusion (LVO) directly to comprehensive stroke centers (CSCs), a process that can potentially result in CSC over-triage and tPA delay. Hypothesis: We hypothesize that simulation modeling can identify optimal characteristics of an EMS protocol that directly transports patients with suspected LVO to CSCs. Methods: Simio (Simio LLC, Sewickely, PA) was used to develop and test a simulation model estimating tPA and ERT rates among EMS-transported patients if an EMS preferential triage policy were implemented in a large, urban EMS system with 23 primary stroke centers (PSC) and 7 CSCs. The process map included time from symptom onset to calling 911, stroke severity, accuracy of field LVO identification, scene and interfacility transport times, and time from hospital arrival to treatment. Current state estimates were obtained from the Get With the Guidelines-Stroke registry, into which the EMS system’s PSCs and CSCs report data. Results: Table 1 shows current treatment rates, theoretical maximum treatment rates (if CSC transport time = 0), and treatment and CSC transport rates in simulations varying symptom onset time as a cut-off criterion for direct transport to a CSC rather than a closer PSC. In sensitivity analysis, accuracy of field LVO identification and interfacility transfer time had the largest positive and negative effect, respectively, on the primary outcomes. Conclusions: Direct transport of patients with suspected LVO who have symptom onset greater than 2 hours prior to EMS arrival is predicted to result in high treatment rates with only a modest increase in the number of patients transported to CSCs and without delaying tPA. Accuracy of field LVO identification and interfacility transport processes may be targets for optimizing EMS stroke systems of care.

Cardiac arrest in public areas: EuReCa_Serbia

Aims: The aim was to observe the frequency of out-of-hospital cardiac arrest outside the place of residence, registered to occur at the streets, working areas and public institutions. Methodology: Data were collected through a unified questionnaire and entered into the EuReCa Serbia cardiac arrest register. The EuReCa Serbia program was conducted as a prospective, observational study as a part of the European Resuscitation Council trial under the number NCT02236819 registered in trials and approved by health authorities in the United States. The entered data were collected in the period from October 1, 2014 to August 1, 2017. The Utstein protocol was used, and EuReCa events were included into unified database via online entries at www.eureca.rs. This includes EuReCa events for those who experienced an out-of-hospital cardiac arrest and were treated by cardiopulmonary resuscitation by the Emergency Medical Emergency Services in public areas. The study protocol defines a public area as a street, a working area, and public institutions. All other EuReCa events which did not occur in a public areas were excluded from this study. The results were analyzed by the statistical program SPSS. Results: In the period from October 2014 to August 2017, 1385 patients were registered with undertaken cardiopulmonary resuscitation (CPR) by the emergency medical services (EMS). In the public areas CPR were applied in 181/1385 (13%) cases. Related to public areas, OHCA most often appear on the streets 101/181 (56%), then in public buildings 55/181 (30%), while at the workplaces is 25/181 (14%). Gender distribution indicates that the males were presented with 151/181 (83%) while the females in 30/181 (17%). 136/181 (75%) collapses was witnessed, 20/181 (11%) OHCA happened before the arrival of EMS, while 25/181 (14%) were not witnessed. Dispatcher assisted resuscitation happened in 4/181 (2%) cases. The witness started the CPR in 15/136 (11%) cases, while in 121/136 the CPR was not initiated by the witnesses (89%). The initial shockable rhythm was recorded in 75/181 (41%) cases. ROSC was achieved in 59/181 (33%) cases. According to the collected information, the hospital discharge was present in 13/181 (7%) cases. The 30 days survival after hospital discharge 12/181 (7%). All 30 days survivors were male with average age of 65. Among the survivors, at four patients laymen initiated CPR was performed. The initially shockable rhythm was recorded at 11/12 (92%) patients. Conclusion: According to the collected data's in this study, EuReCa events in public areas are relatively rare but dramatic because they are happening in front of the public which might bring up many challenges before the arrival of the emergency medical service. The active participation of witnesses and/or laypersons in performing basic life support (BLS) and CPR would significantly increase ROSC and overall survival. The insufficient number of cases highlights the need for further monitoring of the active involvement of CPR witnesses on scene and the impact on the outcome of cardiac arrest in public areas.

Exploring How Lay Rescuers Overcome Barriers to Provide Cardiopulmonary Resuscitation: A Qualitative Study.

Survival rates after out-of-hospital cardiac arrest (OHCA) vary considerably among regions. The chance of survival is increased significantly by lay rescuer cardiopulmonary resuscitation (CPR) before Emergency Medical Services (EMS) arrival. It is well known that for bystanders, reasons for not providing CPR when witnessing an OHCA incident may be fear and the feeling of being exposed to risk. The aim of this study was to gain a better understanding of why barriers to providing CPR are overcome. Using a semi-structured interview guide, 10 lay rescuers were interviewed after participating in eight OHCA incidents. Qualitative content analysis was used. The lay rescuers were questioned about their CPR-knowledge, expectations, and reactions to the EMS and from others involved in the OHCA incident. They also were questioned about attitudes towards providing CPR in an OHCA incident in different contexts. The lay rescuers reported that they were prepared to provide CPR to anybody, anywhere. Comprehending the severity in the OHCA incident, both trained and untrained lay rescuers provided CPR. They considered CPR provision to be the expected behavior of any community citizen and the EMS to act professionally and urgently. However, when asked to imagine an OHCA in an unclear setting, they revealed hesitation about providing CPR because of risk to their own safety. Mutual trust between community citizens and towards social institutions may be reasons for overcoming barriers in providing CPR by lay rescuers. A normative obligation to act, regardless of CPR training and, importantly, without facing any adverse legal reactions, also seems to be an important factor behind CPR provision. Mathiesen WT , Bjørshol CA , Høyland S , Braut GS , Søreide E . Exploring how lay rescuers overcome barriers to provide cardiopulmonary resuscitation: a qualitative study. Prehosp Disaster Med. 2017;32(1):27-32.

D10 in the Treatment of Prehospital Hypoglycemia: A 24 Month Observational Cohort Study

Introduction: Prehospital first responders historically have used an IV bolus of 50 mL of 50% dextrose solution (D50) for the treatment of hypoglycemia in the field. A local Emergency Medical Services (EMS) system recently approved a hypoglycemia treatment protocol of IV 10% dextrose solution (D10) due to occasional shortages and higher cost of D50. We use the experience of this EMS system to report the feasibility, safety, and efficacy of this approach. Methods: Over the course of 104 weeks, paramedics treated 1,323 hypoglycemic patients with D10 and recorded patient demographics and clinical outcomes. Of these, 1,157 (87.5%) patients were treated with 100 mL of D10 initially upon EMS arrival, and full data on response to treatment was available on 871 (75%) of these 1,157. We captured the 871 patients’ capillary glucose response to initial infusion of 100 mL of D10 and fit a linear regression line between elapsed time and difference between initial and repeat glucose values. We also explored the need for repeat glucose infusions as well as feasibility, and safety. Results: The study cohort included 469 men and 402 women with a median age of 66. The median initial field blood glucose was 37 mg/dL, while the subsequent blood glucose had a median of 91 mg/dL. The median time to second glucose testing was eight minutes after beginning the 100mL D10 infusion. Of 871 patients, 200 (23.0%) required an additional dose of IV D10 solution due to persistent or recurrent hypoglycemia and seven (0.8%) patients required a third dose. There were no reported deaths or other adverse events related to D10 administration for hypoglycemia. Linear regression analysis of elapsed time and difference between initial and repeat glucose values showed near-zero correlation. Conclusions: The results of one local EMS system over a 104-week period demonstrate the feasibility, safety, and efficacy of using 100 mL of D10 as an alternative to D50. D50 may also have theoretical risks including extravasation injury, direct toxic effects of hypertonic dextrose, and potential neurotoxic effects of hyperglycemia. Additionally, our data suggest that there may be little or no short-term decrease in blood glucose results after D10 administration.

Association of Bystander Cardiopulmonary Resuscitation and Survival According to Ambulance Response Times After Out-of-Hospital Cardiac Arrest.

Bystander-initiated cardiopulmonary resuscitation (CPR) increases patient survival after out-of-hospital cardiac arrest, but it is unknown to what degree bystander CPR remains positively associated with survival with increasing time to potential defibrillation. The main objective was to examine the association of bystander CPR with survival as time to advanced treatment increases. We studied 7623 out-of-hospital cardiac arrest patients between 2005 and 2011, identified through the nationwide Danish Cardiac Arrest Registry. Multiple logistic regression analysis was used to examine the association between time from 911 call to emergency medical service arrival (response time) and survival according to whether bystander CPR was provided (yes or no). Reported are 30-day survival chances with 95% bootstrap confidence intervals. With increasing response times, adjusted 30-day survival chances decreased for both patients with bystander CPR and those without. However, the contrast between the survival chances of patients with versus without bystander CPR increased over time: within 5 minutes, 30-day survival was 14.5% (95% confidence interval [CI]: 12.8-16.4) versus 6.3% (95% CI: 5.1-7.6), corresponding to 2.3 times higher chances of survival associated with bystander CPR; within 10 minutes, 30-day survival chances were 6.7% (95% CI: 5.4-8.1) versus 2.2% (95% CI: 1.5-3.1), corresponding to 3.0 times higher chances of 30-day survival associated with bystander CPR. The contrast in 30-day survival became statistically insignificant when response time was >13 minutes (bystander CPR vs no bystander CPR: 3.7% [95% CI: 2.2-5.4] vs 1.5% [95% CI: 0.6-2.7]), but 30-day survival was still 2.5 times higher associated with bystander CPR. Based on the model and Danish out-of-hospital cardiac arrest statistics, an additional 233 patients could potentially be saved annually if response time was reduced from 10 to 5 minutes and 119 patients if response time was reduced from 7 (the median response time in this study) to 5 minutes. The absolute survival associated with bystander CPR declined rapidly with time. Yet bystander CPR while waiting for an ambulance was associated with a more than doubling of 30-day survival even in case of long ambulance response time. Decreasing ambulance response time by even a few minutes could potentially lead to many additional lives saved every year.

Abstract 11985: The Role of Bystanders in Timely CPR and Related Outcomes After Out-of-Hospital Cardiac Arrest

Objective: Without cardiopulmonary resuscitation (CPR), cardiac arrest survival declines 5-10% for every minutes. But, there is a limit to reduce the time from collapse to Emergency medical service (EMS) arrival. This study aimed to examine the association between the time interval from collapse to CPR by EMS providers and related outcomes in patients who received bystander CPR. Methods: A population-based observational study was conducted with out-of-hospital cardiac arrests (OHCA) of cardiac etiology who were witnessed by laypersons in Korea between 2012 and 2014. Exposure variable was the proportion of the time interval from collapse to CPR by EMS providers categorized into quartile groups: group 1 (time &lt; 4 min), group 2 (4 ≤ time &lt; 8), group 3 (8 ≤ time&lt; 15), group 4 (15 ≤ time &lt; 30). Primary endpoint was time interval from collapse to CPR by EMS providers and secondary endpoint were survival to discharge and survival with favorable neurological outcome (Cerebral Performance Category (CPC) 1-2). Multivariable logistic regression analysis was performed. The final model was performed to evaluate interactive effect between bystander CPR and the time interval from collapse to CPR by EMS providers. Results: A total of 15,354 OHCAs were analyzed. Bystander CPR was performed in 8,591 (55.95%). The survival to discharge rate was 10.6% (1632) and favorable neurological outcome was 6.5% (996). In an interaction model of bystander CPR patients, AORs (95% CIs) for survival to discharge rate were 0.89 (0.66-1.20) in group 2, 0.76 (0.57-1.02) in group 3, 0.52 (0.37-0.73) in group 4 compared with group 1. For favorable neurological outcome, AORs were 1.12 (0.77-1.62) in group 2, 0.90 (0.62-1.30) in group 3, 0.59 (0.38-0.91) in group 4. Conclusion: Despite of poor ambulance response time, patients who received bystander CPR would show favorable outcomes. Prompt delivered bystander CPR was strongly associated with increased survival. Keywords: Out-of-hospital cardiac arrest; Cardiopulmonary resuscitation; Emergency medical services

High-rise buildings and neurologically favorable outcome after out-of-hospital cardiac arrest

BackgroundThe number of people living in high-rise buildings has recently been increasing in Japan, and delayed transport time by emergency-medical-service (EMS) personnel from higher floors could lead to lower survival after out-of-hospital cardiac arrest (OHCA). However, there are no clinical studies assessing the association between the floor where patients reside and neurologically favorable outcome after OHCA. MethodsThis was a prospective, population-based study conducted in Osaka City, Japan that enrolled adults aged >=18years suffering an OHCA of cardiac origin before EMS arrival between 2013 and 2014. The primary outcome measure was one-month survival with neurologically favorable outcome. We divided OHCA patients into the following groups: those residing on >=3 floors (the high floor group) and <3 floors (the low floor group). Multiple logistic regression analysis was used to assess factors associated with neurologically favorable outcome. ResultsA total of 2979 patients were eligible for analysis. Of them, 1885 (62.3%) occurred below the third floor and 1094 (37.4%) occurred at or above the third floor. The proportion of neurologically favorable outcome after OHCA was significantly lower in the high floor group than in the low floor group (2.7% [30/1094] versus 4.8% [91/1885], P=0.005). In a multivariate analysis, neurologically favorable outcome after OHCA was significantly lower in the high floor group than in the low floor group (adjusted odds ratio, 0.59 [95% confidence interval, 0.37–0.96]). ConclusionsIn this population, one-month survival with neurologically favorable outcome from OHCA was lower in the high floor group than in the low floor group.