Of-hospital Cardiac Arrest Research Articles

Resuscitative endovascular occlusion of the aorta (REBOA) for refractory out of hospital cardiac arrest. An Utstein-based case series

AimsOut of hospital cardiac arrest (OHCA) is still a leading cause of mortality worldwide. In recent years, resuscitative endovascular balloon occlusion of the aorta (REBOA) has been progressively studied as an adjunct to standard advanced life support (ALS) in both traumatic and non-traumatic refractory OHCA.Since January 2019, the REBOA procedure has been applied to all the patients experiencing both traumatic and non-traumatic refractory OHCA (≥15 min of cardiopulmonary resuscitation) not eligible for ECPR for clinical or logistic reasons.We aimed at describing the feasibility and effects of REBOA performed both in the Emergency Department and in the pre-hospital environment served by the local HEMS for refractory OHCA. MethodsTwenty consecutive patients experiencing refractory OHCA and in whom REBOA was attempted in 2019 and 2020 were included in the study, Utstein data and REBOA specific variables were recorded. ResultsSuccessful catheter placement was achieved in 18 out of 20 patients, 11 of these were non-traumatic OHCAs while 7 were traumatic OHCAs, the 2 failures were related to repeated arterial puncture failure.Median time between the EMS dispatch and REBOA catheter placing attempt was 46 min.An increase in etCO2 over 10 mmHg was observed after balloon inflation in 12 out of 18 patients (8/11 non-traumatic and 4/7 traumatic OHCAs), a sustained ROSC was observed in 5 patients (1 traumatic and 4 non-traumatic OHCA) that were subsequently admitted to the ICU. Four out of the 5 patients reached the criteria for brain death in the subsequent 24 h while one patient experienced another episode of refractory cardiac arrest in ICU and subsequently died. ConclusionOur data confirm the feasibility of REBOA technique as an adjunct to ALS in both the ED and prehospital phase and most of the treated patients experienced a transient ROSC after balloon inflation while 5 out of 18 experienced a sustained ROSC.However, while in the trauma setting increasing evidence suggests an improved survival when REBOA is applied to refractory OHCA, in non-traumatic OHCA this has yet to be demonstrated and large studies are needed.

Association of chain of survival factors with out of hospital cardiac arrest survival in a region with low average population-density: a retrospective population-based cohort study

Abstract Background Out of hospital cardiac arrest (OHCA) has an average global survival rate to discharge of 8%. Chain of survival factors are heavily time-dependant and optimization can increase survival. Regions with low population density encounter challeges in providing optimal OHCA care. Nova Scotia's average population density is 17.4 persons per square kilometer in compasiron to Toronto with 4334.4 person per square kilometer. OHCAs have been described well in large urban centers globally, however the characterization of OHCA chain of survival in low density populations is sparse. Purpose To describe chain of survival factors and identify characteristics of survivors and non-survivors among those treated by paramedics in a low average density provincial population. Methods This was a retrospective cohort study of OHCAs responded to by paramedics. All OHCA responses with a cardiac etiology in Nova Scotia, Canada were included. Exclusion criteria were non-cardiac cause arrests, those with “do not resuscitate” (DNR) directives and expected deaths. The paramedic electronic patient care record was reviewed for demographic, bystander, out of hospital treatment and operational characteristics. Primary outcome was survival to hospital discharge. Descriptive statistics were calculated to describe differences between survivorship using Prism 8.0 (San Diego, CA) with alpha=0.05 applying unpaired, Mann-Whitney tests. Results Of 1517 OHCA, 463 were excluded leaving 1054 OHCA. Of these, 478 (45.3%) were treated by paramedics and included in this analysis. Most were men (67.2%; n=274) with a mean age 66.8 (±16.4). A total of 7.1% (n=75) survived to discharge with 76% of survivors (n=58) discharged home. Survivors were more likely to present with ventricular fibrillation than non-survivors (42.7% vs. 19.6%). Survivors compared to non-survivors had significantly shorter paramedic response time (8.1 vs. 10.7 min, P<0.001), paramedic time on scene (35.7 vs. 45.4 min, P=0.002), estimated time to paramedic defibrillation (13.2 vs 19.4 min, P<0.001), and estimated time to return of spontaneous circulation (ROSC) (22.9 vs 31.9min, P<0.001). Conclusion Links in the chain of survival are associated with survival from OHCA. OHCA survival is lower in the less densely populated province of Nova Scotia compared to studies in urban Canadian centers and worldwide. Our study is limited by the retrospective nature of data collection and lack of access to neurological outcomes. Even among survivors, EMS response is delayed compared to more densely populated centers. In Nova Scotia, longer paramedic response times are associated with decreased survival. Funding Acknowledgement Type of funding source: Other. Main funding source(s): Maritime Heart Center

Safety and benefit of Glycoprotein IIb/IIIa inhibitors in out of hospital cardiac arrest patients treated with percutaneous coronary intervention

BackgroundOut of hospital cardiac arrest (OHCA) patients requiring percutaneous coronary intervention (PCI) are at higher risk of both stent thrombosis and bleeding. The use of aggressive antiplatelet therapy could lead to a higher risk of bleeding in these patients. Indeed, data on glycoprotein IIb/IIIa inhibitor (GPi) use in this specific indication is scarce. AimWe sought to evaluate the benefit and safety of GPi use in OHCA patients requiring PCI. Methods and resultsBetween January 2007 and December 2017, we retrospectively included all consecutive patients treated with PCI for an OHCA from cardiac cause. Clinical, procedural data and in-hospital outcomes were collected. Three hundred and eighty-five patients were included. GPi were administrated in 41.3% of cases (159 patients). Patients who received GPi were younger, had less prior PCI, more often a TIMI 0 or 1 flow before PCI and thromboaspiration use. There were no differences regarding in-hospital definite stent thrombosis among the two groups (11.9% in the GPi group vs 7.1% in the non-GPi group, p = 0.10) or in-hospital mortality (48.6% vs 49.3%, p = 0.68). The incidence of any bleeding (33.3% vs. 19.6%; p = 0.002), and major bleeding (BARC 3−5) (21.9% vs. 16.8%; p = 0.007) was significantly higher in patients receiving GPi. Indeed, using multivariate analysis, GPi use was predictor of major bleeding (OR: 1.81; 95% CI: 1.06−3.08; p = 0.03). ConclusionsIn patients treated with PCI for OHCA from cardiac cause, GPi use was associated with an increased risk of major bleeding events, without difference on in-hospital stent thrombosis or death.

Ultrasound-Guided Chest Compressions in Out-of-Hospital Cardiac Arrests

There is a significant variability in survival rates for cardiopulmonary resuscitation (CPR) in out of-hospital cardiac arrest (OHCA), and some data indicate that ultrasound improves CPR. We evaluated the feasibility of ultrasound for monitoring chest compressions in OHCA. We planned a prospective study in patients with an ultrasound-integrated CPR for OHCA. Chest compressions were performed on the intermammillary line (IML), but the position was changed according to the quality of the heart squeezing, evaluated by ultrasound. End-tidal carbon dioxide (ETCO2) was used as the control parameter. Then we compared the area with the highest squeezing with the position of the heart in the chest computed tomography (CT) scans of 20 hospitalized patients. Chest compressions were good, partial, and inadequate on the IML in 58.4%, 48.9%, and 2.8% of cases, respectively. These percentages were 75%, 25%, and 0% after these modifications: none (47.2%), increased depth (8.3%), hands moved on the lower third of the sternum (27.8%), on left parasternal line of the lower part of the sternum (13.9%), and on the center of the sternum (1 case). Accordingly, ETCO2 improved significantly (20.37 vs. 37.10, p<0.0001). The CT scans showed that the larger biventricular area (BVA) was under the parasternal line of the lower third of the sternum, and the mean distance IML-BVA was 5.7cm. Our study has demonstrated that CPR in OHCA can be improved using ultrasound and changing the position of the hands. This finding was connected with the ETCO2 and confirmed by chest CT scans.

Patient safety incidents and medication errors during a clinical trial: experience from a pre-hospital randomized controlled trial of emergency medication administration

To assess and evaluate patient safety incidents and in particular, medication errors, during a large multi-center pre-hospital trial of emergency therapy (PARAMEDIC2), in order to inform and improve future pre-hospital medicines trials. The PARAMEDIC2 trial was undertaken across five NHS Ambulance Services in England and Wales with randomisation between December 2014 and October 2017. Patients with an out -of-hospital cardiac arrest unresponsive to initial resuscitation were randomly assigned to 1mg intravenous adrenaline or matching placebo. Records were reviewed to identify trial medication errors involving documentation and/or clinical protocol errors occurring in trial participants. Causes of medication errors, including root cause analysis where available, were reviewed to identify patterns and themes contributing to these errors. Eight thousand sixteen patients were enrolled, of whom 4902 received trial medication. A total of 331 patient safety incidents was reported, involving 295 patients, representing an overall rate of 3.6% of these, 166 (50.2%) were documentation errors while 165 (49.8%) were clinical protocol/medication errors. An overall rate of 0-4.5% was reported across all five ambulance services, with a mean of 2.0%. These errors had no impact on patient care or the trial and were all resolved CONCLUSION: The overall medication error rate of 1.8% primarily consisted of administration of open-label adrenaline and confusion with trial medication packs. A similar number of patients had documentation errors. This study is the first to provide data on patient safety incidents relating to medication errors encountered during a pre-hospital trial of emergency medication administration and will provide supporting data for planning future trials in this area.

A needs assessment of resuscitative endovascular balloon occlusion of the aorta (REBOA) in non-traumatic out-of-hospital cardiac arrest in Norway

IntroductionOut of hospital cardiac arrest (OHCA) carries an 86% mortality rate in Norway. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a potential adjunct in management of non-traumatic cardiac arrest and is feasible in pre-hospital setting without compromising standard cardiopulmonary resuscitation (CPR). However, number of patients potentially eligible for REBOA remain unknown. In preparation for a clinical trial to investigate any benefit of pre-hospital REBOA, we sought to assess the need for REBOA in Norway as an adjunct treatment in OHCA.MethodsRetrospective observational cohort study of data from the Norwegian Cardiac Arrest Registry in the 3-year period 2016–2018. We identified number of patients potentially eligible for pre-hospital REBOA during CPR, defined by suspected non-traumatic origin, age 18–75 years, witnessed arrest, ambulance response time less than 15 min, treated by ambulance personnel and resuscitation effort over 30 min.ResultsIn the 3-year period, ambulance personnel resuscitated 8339 cases. Of these, a group of 720 patients (8.6%) were eligible for REBOA. Only 18% in this group achieved return of spontaneous circulation and 7% survived for 30 days or more.ConclusionThis national registry data analysis constitutes a needs assessment of REBOA in OHCA. We found that each year approximately 240 patients, or nearly 9% of ambulance treated OHCA, in Norway is potentially eligible for pre-hospital REBOA as an adjunct treatment to standard resuscitation. This needs assessment suggests that there is sufficient patient population in Norway to study REBOA as an adjunct treatment in OHCA.

The value of cerebrospinal fluid ubiquitin C-terminal hydrolase-L1 protein as a prognostic predictor of neurologic outcome in post-cardiac arrest patients treated with targeted temperature management

AimWe evaluated the prognostic value of serum- and cerebrospinal fluid (CSF)-ubiquitin carboxyl-terminal esterase L1 protein (UCHL1) measurements in post- post-out of hospital cardiac arrest (OHCA) patients treated with target temperature management (TTM), to predict neurologic outcome. MethodsThis was a prospective single-centre observational cohort study, conducted from April 2018 to September 2019. Serum- and CSF-UCHL1 were obtained immediately (UCHL1initial), 24 h (UCHL124), 48 h (UCHL148), and 72 h (UCHL172) after return of spontaneous circulation (ROSC). The area under the receiver operating characteristic curves (AUROC) and Delong method were used to identify cut-off values of serum- and CSF-UCHL1initial, UCHL124, UCHL148, UCHL172 for predicting neurologic outcomes. ResultsOf 38 patients enrolled, 16 comprised the poor outcome group. The AUROCs for serum- and CSF-UCHL1initial were 0.71 and 0.93 in predicting poor neurological outcomes, respectively (p = 0.01). The AUROCs for serum- and CSF-UCHL124 were 0.85 and 0.91 (p = 0.24). The AUROCs for serum- and CSF-UCHL148 were 0.90 and 0.97 (p = 0.07). The AUROCs for serum- and CSF-UCHL172 were 0.94 and 0.98 (p = 0.25). ConclusionFindings of this study demonstrate that CSF-UCHL1 measured immediately, 24, 48, and 72 h after ROSC is a valuable predictor for evaluating neurologic outcomes, whereas serum-UCHL1 measured at 24, 48, and 72 h after ROSC showed a significant performance in the prognostication of poor outcomes in post-OHCA patients treated with TTM.

6031Out -of-hospital cardiac arrest - incidence of coronary artery disease, co-morbidity and survival

Abstract Background Data from the European Cardiovascular Disease Statistics from 2012 shows that 20% of all deaths are caused by coronary artery disease with cardiac arrest (CA) as the most common scenario. Historic data have shown that coronary artery disease was present in approximately 70% of unselected out-of-hospital CA (OHCA) patients byangiography. As registry and retrospective data are prone to bias it remains unknown whether an early invasive strategy translates into improved outcome, we present our experience from a large urban region of Denmark. Purpose The aim was to describe a consecutive OHCA-cohort with regards to incidence of coronary artery disease, comorbidity and survival rate. Methods A consecutive unselected cohort of patients with OHCA in the Capital Region of Denmark was included (n=1,003) from 2007 to 2011. After successful resuscitation patients were admitted for post-resuscitation care at 1 of 8 hospitals including coronary angiography and percutaneous coronary interventions (PCI) when indicated. Results Patients were 65±15 years old, 71% were male, 52% had shockable primary rhythm, median time to return of spontaneous circulation (ROSC) was 22 minutes (Q1–Q3: 13–37 min), the majority was unconscious at hospital admission (89%), and no previous comorbidity was noted in 52%. The majority of the cohort had OHCA due to a cardiac cause (n=806, 80%). Acute coronary syndrome (ACS) was diagnosed in 39% of the total cohort (n=389), and in 48% of patients with cardiac cause with ST-segment elevation myocardial infarction being more frequent (n=236, 60% of ACS). 30-day mortality was 59% in the total cohort and 46% in patients with ACS (plogrank&lt;0.001). A favourable neurological outcome (Cerebral Performance Category 1 or 2) was noted in 84% of all patients discharged alive (n=347), and in 85% of patients with ACS (n=178). In the total cohort ACS was independently associated with a lower 30-day mortality rate (hazard ratio (HR) = 0.62, 95% confidence interval (CI) 0.51–0.75, p&lt;0.001) after adjustment for age, pre-hospital OHCA circumstances (bystander CPR, public arrest and witnessed arrest), time to ROSC, primary admission to a tertiary heart centre, and degree of comorbidity. In OHCA-patients with ACS only, successful PCI was independently associated with a lower 30-day mortality after adjustment for the mentioned prognostic factors (HR all ACS= 0.46, 95% CI 0.31–0.67, p&lt;0.001, HR STEMI= 0.43, 0.27–0.69, p&lt;0.001, HR NSTEMI= 0.12, 0.03–0.51, p=0.004). Conclusion In an unselected clinical cohort of out-of-hospital cardiac arrest survivors less than half of the patients was diagnosed with acute coronary syndrome. ACS was associated with a better prognosis even after adjustment for prognostic factors. Successful PCI was likewise an independent prognostic factor, however this may be due to selection bias and a direct support of acute angiography in all OHCA-survivors should await the results of randomised clinical trials. Acknowledgement/Funding Trygfonden

院外心肺停止患者予後予測基準の外的妥当性：救急蘇生統計を用いた後方視的検討(External validation of the prediction criteria for the outcome after out–of–hospital cardiac arrest: a retrospective population–based study in Japan)

要旨【目的】我々は以前に（1）73歳以上，（2）目撃がない，（3）初回心電図波形が非除細動適応波形である，の3項目により院外心肺停止患者の機能予後不良を高い精度で予測することが可能であると報告した。本研究は同予後予測基準の外的妥当性を検証することを目的として実施された。【対象と方法】総務省消防庁の提供する救急蘇生統計（2013年から2016年）を用いて，予後予測基準該当の有無と，1か月後機能予後不良（脳機能カテゴリー3から5）の有無を調査し，同基準の予後予測精度を評価した。地域特異的な検査精度を評価すべく，人口密度に基づいたサブグループ解析を行った。【結果】解析対象となった498,040例のうち，188,233例（37.8%）が予後予測基準に合致した。同基準による１か月後機能予後不良予測の特異度は0.951（95%信頼区間 0.948–0.954），陽性的中率は0.995（95%信頼区間 0.995–0.996）であった。陽性的中率は各年代を通して0.995–0.996であった。サブグループ解析の結果，地域人口密度によらず，陽性的中率は0.995–0.997であった。【結語】（1）73歳以上，（2）目撃がない，（3）初回心電図波形が非除細動適応波形である，の3項目を救急隊到着時に満たす場合，院外心肺停止患者の機能予後は極めて高い確率で不良であることが示された。

Time of on-scene resuscitation in out of-hospital cardiac arrest patients transported without return of spontaneous circulation

BackgroundIn out-of-hospital cardiac arrest (OHCA), return of spontaneous circulation (ROSC) on scene occurs only in a minority of patients. The optimal duration of resuscitation on scene before transport with ongoing cardiopulmonary resuscitation (CPR) is unknown. PurposeTo determine the time of resuscitation on scene (‘time on scene’) and survival in patients transported with ongoing CPR in the Netherlands. MethodsData on OHCA patients (>18 years) without ROSC on scene, where resuscitation was started between January 1, 2012 and December 31, 2016 in the Amsterdam Resuscitation Study (ARREST) database were analyzed. Time on scene was related to 30-day survival. ResultsOf the 5871 OHCA patients where resuscitation was started, 2437 did not achieve ROSC on scene. Of these, 655 patients were transported with ongoing CPR and 606 (93%) had complete rhythm data. At the moment of transport, 199 (33%) patients had a shockable rhythm, 299 (49%) pulseless electrical activity (PEA) and 108 (18%) asystole as rhythm. Twenty-nine patients (4%) were alive at 30 days. Patients who survived 30 days had a higher proportion of a shockable first monitored rhythm (89% vs. 52%, p < 0.001). Survivors had a significantly shorter time on scene (20 min vs. 26 min, p = 0.004), with the highest survival rate (8%) in patients transported within 20 min. In a multivariable model time on scene (OR 0.94; 95%CI 0.89–0.99) was independently associated with 30-day survival. ConclusionIn OHCA patients transported with ongoing CPR the survival rate significantly declines when time on scene increases.

Global resuscitation alliance utstein recommendations for developing emergency care systems to improve cardiac arrest survival

IntroductionThe Global Resuscitation Alliance (GRA) was established in 2015 to improve survival for Out- of-Hospital Cardiac Arrest (OHCA) using the best practices developed by the Seattle Resuscitation Academy. However, these 10 programs were recommended in the context of developed Emergency Care Systems (ECS). Implementing these programs can be challenging for ECS at earlier stages of development. We aimed to explore barriers faced by developing ECS and to establish pre-requisites needed. We also developed a framework by which developing ECS may use to build their emergency response capability. MethodA consensus meeting was held in Singapore on 1st–2nd August 2017. The 74 participants were key stakeholders from 26 countries, including Emergency Medical Services (EMS) directors, physicians and academics, and two Physicians who sit on the World Health Organisation (WHO) panel for development of Emergency Care Systems. Five discussion groups examined the chain of survival: community, dispatch, ambulance and hospital; a separate group considered perinatal resuscitation. Discussion points were voted upon to reach a consensus. ResultsThe answers and discussion points from each groupwere classified into a table adapted from WHO’s framework of development for Emergency Services. After which, it was used to construct the modified survival framework with the chain of survival as the backbone. Eleven key statements were then derived to describe the pre-requisites for achieving the GRA 10 programs. The participants eventually voted on the importance and feasibility of these 11 statements as well as the GRA 10 programs using a matrix that is used by organisations to prioritise their action steps. ConclusionIn this paper, we propose a modified framework of survival for developing ECS systems. There are barriers for developing ECS systems to improve OHCA survival rates. These barriers may be overcome by systematic prioritisation and cost-effective innovative solutions.

Epidemiology and outcome of paediatric out-of-hospital cardiac arrests: A paediatric sub-study of the Pan-Asian resuscitation outcomes study (PAROS)

BackgroundThe Pan Asian Resuscitation Outcomes Study (PAROS) is a retrospective study of out- of-hospital cardiac arrest(OHCA), collaborating with EMS agencies and academic centers in Japan, South Korea, Malaysia, Singapore, Taiwan, Thailand and UAE-Dubai. The objectives of this study is to describe the characteristics and outcomes, and to find factors associated with survival after paediatric OHCA. MethodsWe studied all children less than 17 years of age with OHCA conveyed by EMS and non-EMS transports from January 2009 to December 2012. We did univariate and multivariate logistic regression analyses to assess the factors associated with survival-to-discharge outcomes. ResultsA total of 974 children with OHCA were included. Bystander cardiopulmonary resuscitation rates ranged from 53.5% (Korea), 35.6% (Singapore) to 11.8% (UAE). Overall, 8.6% (range 0%–9.7%) of the children survived to discharge from hospital. Adolescents (13–17 years) had the highest survival rate of 13.8%. 3.7% of the children survived with good neurological outcomes of CPC 1 or 2. The independent pre-hospital factors associated with survival to discharge were witnessed arrest and initial shockable rhythm. In the sub-group analysis, pre-hospital advanced airway [odds ratio (OR) = 3.35, 95% confidence interval (CI) = 1.23–9.13] was positively associated with survival-to-discharge outcomes in children less than 13 years-old. Among adolescents, bystander CPR (OR = 2.74, 95%CI = 1.03–7.3) and initial shockable rhythm (OR = 20.51, 95%CI = 2.15–195.7) were positive factors. ConclusionThe wide variation in the survival outcomes amongst the seven countries in our study may be due to the differences in the delivery of pre-hospital interventions and bystander CPR rates.

体外式人工肺装置導入患者における便失禁管理システムの有用性に関する検討(Benefit of fecal incontinence management system during extracorporeal membrane oxygenation)

要旨鼠径部はしばしば便失禁により汚染するが，血管内留置カテーテルへの便汚染を回避する目的で便失禁管理システム（fecal incontinence management system: FMS）を使用した報告は少なく，その有用性を検証した。2010年1月から2015年12月の間に院外心停止（out–of–hospital cardiac arrest: OHCA）に対して体外循環式心肺蘇生（extracorporeal cardiopulmonary resuscitation: ECPR）を行った体外式人工肺装置（extracorporeal membrane oxygenation: ECMO）導入患者のうち，入院後48時間以内の死亡症例，入院後48時間以内のECMO離脱症例を除き，FMSの使用群（31例）と非使用群（32例）について後方視的に検討した。両群間に年齢，性別，体温管理療法や予防的抗菌薬の使用の有無などに差はなく，ECMOカテーテルの留置期間の中央値はいずれも4日であった。入院中の菌血症は非使用群で6例（19%）にみられ，使用群では菌血症は皆無であった（P=0.024）。ECPRでのOHCAに対するECMO導入患者に対し，FMSが菌血症の発症抑制に関与している可能性が示唆された。

Post-resuscitation arterial oxygen and carbon dioxide and outcomes after out-of-hospital cardiac arrest

ObjectiveTo determine if arterial oxygen and carbon dioxide abnormalities in the first 24h after return of spontaneous circulation (ROSC) are associated with increased mortality in adult out-of-hospital cardiac arrest (OHCA). MethodsWe used data from the Resuscitation Outcomes Consortium (ROC), including adult OHCA with sustained ROSC ≥1h after Emergency Department arrival and at least one arterial blood gas (ABG) measurement. Among ABGs measured during the first 24h of hospitalization, we identified the presence of hyperoxemia (PaO2≥300mmHg), hypoxemia (PaO2<60mmHg), hypercarbia (PaCO2>50mmHg) and hypocarbia (PaCO2<30mmHg). We evaluated the associations between oxygen and carbon dioxide abnormalities and hospital mortality, adjusting for confounders. ResultsAmong 9186 OHCA included in the analysis, hospital mortality was 67.3%. Hyperoxemia, hypoxemia, hypercarbia, and hypocarbia occurred in 26.5%, 19.0%, 51.0% and 30.6%, respectively. Initial hyperoxemia only was not associated with hospital mortality (adjusted OR 1.10; 95% CI: 0.97–1.26). However, final and any hyperoxemia (1.25; 1.11–1.41) were associated with increased hospital mortality. Initial (1.58; 1.30–1.92), final (3.06; 2.42–3.86) and any (1.76; 1.54–2.02) hypoxemia (PaO2<60mmHg) were associated with increased hospital mortality. Initial (1.89; 1.70–2.10); final (2.57; 2.18–3.04) and any (1.85; 1.67–2.05) hypercarbia (PaCO2>50mmHg) were associated with increased hospital mortality. Initial (1.13; 0.90–1.41), final (1.19; 1.04–1.37) and any (1.01; 0.91–1.12) hypocarbia (PaCO2<30mmHg) were not associated with hospital mortality. ConclusionsIn the first 24h after ROSC, abnormal post-arrest oxygen and carbon dioxide tensions are associated with increased out of-hospital cardiac arrest mortality.

The time period of on-scene resuscitation in out of-hospital cardiac arrest patients transported without return of spontaneous circulation

The time period of on-scene resuscitation in out of-hospital cardiac arrest patients transported without return of spontaneous circulation

Impact of city police layperson education and equipment with automatic external defibrillators on patient outcome after out of hospital cardiac arrest

IntroductionOut of hospital cardiac arrest (OHCA) occurs frequently and the outcome is often dismal. Early defibrillation saves lives and brain function in OHCA. The Zurich city police (STAPO) forces were instructed and equipped to provide basic life support (BLS) and to use an AED in 2009. MethodsRetrospective observational study comparing period 1 (P1) 2004–2009 before equipping and training of the STAPO and period 2 (P2) 2010–2015 after the implementation. Patients suffering from OHCA of cardiac or presumed cardiac origin in the city of Zurich undergoing CPR by EMS in P1 (n=709) and P2 (n=684) were included. Intervention periods and outcome were compared between the periods. Outcome variables were adjusted for patient age and gender, witnessed status, and defibrillation by the EMS, STAPO, layperson or no defibrillation. ResultsIn P2, CPR was started by the STAPO in a median of 8 (IQR 6–9) minutes after the arrest and thus significantly earlier (median 3min) than by the EMS (p<0.001). STAPO performed the first defibrillation in a median of 9 (IQR 8–10) minutes and thus significantly earlier (median 6min) than the EMS (p<0.001). Outcome improved significantly in P2: proportion of patients with return of spontaneous circulation (ROSC, P2 35.8%, P1 24.0%, OR 1.8, 95% CI 1.4–2.2, p<0.001), hospital admission (P2 32.2%, P1 21.4%, OR 1.7, 95% CI 1.4–2.2, p<0.001) and survival to hospital discharge (P2 13.6%, P1 6.9%, OR 2.1 95% CI 1.5–3.0, p<0.001). If the patient was firstly defibrillated by the STAPO, ROSC (STAPO 74.4%, adj. OR 2.6, 95% CI 1.3–5.4, p=0.010) and hospital admission (STAPO 72.1%, adj. OR 2.8, 95% CI 1.4–5.6, p=0.005) was higher compared to patients firstly defibrillated by the EMS. Survival to hospital discharge (STAPO 30.2%, adj. OR 1.4, 95% CI 0.7–2.9, p=0.38) was unchanged. ConclusionDispatching BLS trained and AED equipped police forces results in earlier and more successful resuscitation of OHCA victims, leading to higher proportions of patients with ROSC, hospital admission and survival to hospital discharge.

22 Factors associated with poor outcome in patients taken to the catheter lab after out of hospital cardiac arrest

IntroductionOut of hospital cardiac arrest (OHCA) represents a common presentation to both the emergency department and the catheter lab. Understanding of the factors associated with poor outcome in this patient...

A Pre-Hospital Extracorporeal Cardio Pulmonary Resuscitation (ECPR) strategy for treatment of refractory out hospital cardiac arrest: An observational study and propensity analysis

BackgroundOut of hospital cardiac arrest (OHCA) mortality rates remain very high with poor neurological outcome in survivors. Extracorporeal cardiopulmonary resuscitation (ECPR) is one of the treatments of refractory OHCA. This study used data from the mobile intensive care unit (MOICU) as part of the emergency medical system of Paris, and included all consecutive patients treated with ECPR (including pre-hospital ECPR) from 2011 to 2015 for the treatment of refractory OHCA, comparing two historical ECPR management strategies. MethodsWe consecutively included refractory OHCA patients. In Period 1, ECPR was indicated in selected patients after 30min of advanced life support; in- or pre-hospital implementation depended on estimated transportation time and ECPR team availability. In Period 2, patient care relied on early ECPR initiation after 20min of resuscitation, stringent patient selection, epinephrine dose limitation and deployment of ECPR team with initial response team. Primary outcome was survival with good neurological function Cerebral Performance Category score (CPC score) 1 and 2 at ICU discharge or day 28. FindingsA total of 156 patients were included. (114 in Period 1 and 42 in Period 2). Baseline characteristics were similar. Mean low-flow duration was shorter by 20min (p<0.001) in Period 2. Survival was significantly higher in Period 2: 29% vs 8% (P<0.001), as confirmed by the multivariate analysis and propensity score. When combining stringent patient selection with an aggressive strategy, the survival rate increased to 38%. Pre-hospital ECPR implementation in itself was not an independent predictor of improved survival, but it was part of the strategy in Period 2. InterpretationOur data suggest that ECPR in specific settings in the management of refractory OHCA is feasible and can lead to a significant increase in neurological intact survivors. These data, however, need to be confirmed by a large RCT.

Abstract 92: Documentation Discrepancies of Time-Dependent Critical Events in Out of Hospital Cardiac Arrest

Background: The timing of and interval between prehospital interventions and patient-related events during out of-hospital cardiac arrest (OHCA) resuscitation are important for system design and patient outcome. Since most prehospital research relies on data abstraction from the medical record, it is imperative to assure the accuracy and precision of time-stamped events in prehospital documentation. Austere environments and/or limited human resources may impair the accuracy and precision of this documentation. OHCA is a time-sensitive disease that necessitates rapid interventions; even small errors in timing documentation may introduce unrecognized bias into analysis. Objective: Determine the accuracy and precision of EMS documentation of time-stamped events during OHCA. Hypothesis: Times of critical events (CE) in OHCA documented by EMS are inaccurate when compared to audio documentation of the same cases. Methods: We reviewed prehospital documentation of OHCA resuscitation from two regional EMS agencies. We abstracted the documented times of CE in the prehospital medical record, as well as synchronized, time-stamped audio recordings from the monitor/defibrillator corresponding to each case. CE included IV/IO access, first epinephrine administration, successful airway placement, and return of spontaneous circulation. We compared the difference in minutes between medical record and audio sources, rounding down to the whole minute. Results: A total of 411 patients suffered OOHCA during the study period. Of these, 192 patients had both documentation times and audio times for at least one CE. A total of 422 CEs were documented. A median absolute difference of 2 minutes (IQR 1-4 minutes) was found for all CE. 136 (32.8%) of the cardiac arrest cases had 2 or more CE documented. There was a median discrepancy of 4.5 minutes (Range 0-27, IQR 1-4.5) in the interval between CE in the same case. Within case error shows that the differences are random, and not simply related to synchronization of timing devices. Conclusion: Documentation may introduce an error of 2 minutes in the times of CE and 4.5 minutes in the estimated intervals between CE. These errors are meaningful for studies of time dependent diseases like OHCA.