Out-of-hospital Cardiac Arrest In Japan Research Articles

Impact of the number of citizens officially certified for government-organized civilian cardiopulmonary resuscitation courses on the prognosis for patients with out-of-hospital cardiac arrest in Japan

Abstract Background To improve the prognosis of patients with out-of-hospital cardiac arrest (OHCA), the rate of high-quality cardiopulmonary resuscitation (CPR) and immediate use of automated external defibrillators (AEDs) by citizens must be further increased. Japanese government launched certified CPR courses for citizens throughout Japan in 1994 and the number of citizens certified on the course is increasing. However, the impact of the number of citizens officially certified for the courses on the rate of CPR implementation by citizens and the outcomes in patients with OHCA is unclear. Methods From a prospective, nationwide, population-based registry of patients with OHCA in Japan, we identified 350,444 patients from 2005 through 2020 with bystander-witnessed OHCA with 72,069 ventricular-fibrillation (VF) and the other non-VF cardiac arrests. The association between the number of citizens certified for the CPR courses and the rate of CPR implementation by citizens throughout Japan was analyzed by Poisson distribution and Cochran–Armitage test for trend. The primary outcome was survival at 1 month. The secondary outcomes were favorable neurologic outcome at 1 month. The associations between the CPR attempted by citizens [categorized into three (chest-compression-only CPR, chest compression with rescue breathing, and use of AEDs with chest compression and rescue breathing)] and outcomes were determined by multivariable mixed logistic regression analyses. Results Cumulative number of citizens certified for the CPR courses increased from 717,808 in 2005 to 34,938,322 in 2020, which reached to 27.8% of total Japanese population. Annual course receivers were also linearly increased during the period (Incidence Rate Ratios 1.03, p<0.001). Similarly, the rate of patients receiving CPR by citizens increased linearly from 40.6% in 2005 to 56.8% in 2020 (P for trend<0.001). In the multivariable mixed logistic regression analyses, higher CPR activity by citizens were significantly associated with better 1-year survival in both VF and non-VF patients even after adjusted for covariates [VF = chest compression: odds ratio (OR) 1.17; 95% confidence interval (CI) 0.98–1.39; P =0.078; chest compression with rescue breathing: OR 1.22; 95% CI 1.02–1.49; P =0.030; use of AEDs with chest compression and rescue breathing: OR 1.54; 95% CI 1.54–1.92; P <0.001 vs no CPR, non-VF= chest compression: OR 1.19; 95% CI 0.76–1.87; P =0.45; chest compression with rescue breathing: OR 2.26; 95% CI 1.34–3.82; P =0.020 vs non-CPR]. Similar results were also found in neurological outcomes in 1 month. Conclusions The rate of CPR implementation by citizens throughout Japan has continuously and linearly increased in these 15 years in proportion to the increase in the number of citizens certified for the government-organized CPR courses. Higher CPR activity by citizens were significantly associated with better 1-year survival and favorable functional status in both VF and non-VF patients.

An epidemiological assessment of choking-induced out-of-hospital cardiac arrest: A post hoc analysis of the SOS-KANTO 2012 study

ObjectivesThe aim of this study was to reveal the neurological outcomes of choking-induced out-of-hospital cardiac arrest (OHCA) and evaluate the presence of witnesses, cardiopulmonary resuscitation (CPR) performed by a witness (bystander-witnessed CPR), and the proportion of patients with favourable neurological outcomes by the time from CPR by emergency medical services (EMS) to the return of spontaneous circulation (ROSC) (CPR-ROSC time). MethodsWe retrospectively analysed the SOS-KANTO 2012 database, which included data of 16,452 OHCAs in Japan. We selected choking-induced OHCA patients aged ≥ 20 years. We evaluated the neurological outcomes at 1 month with the Cerebral Performance Category (CPC). We defined favourable neurological outcomes (CPCs: 1–2) and present the outcomes with descriptive statistics. ResultsOf 1,045 choking-induced OHCA patients, 18 (1.7%) had a favourable neurological outcome. Of 1,045 OHCAs, 757 (72.6%) were witnessed, and 375 (36.0%) underwent bystander-witnessed CPR. Of the 18 OHCAs with favourable outcomes, 17 (94.4%) were witnessed, and 11 (61.1%) underwent bystander-witnessed CPR. With a CPR-ROSC time of 0–5 minutes, the proportion of patients with favourable neurological outcomes was 29.7%, ranging from 0% to 6% in the following time groups. ConclusionsThe neurological outcome of choking-induced OHCA was poor. The neurological outcomes deteriorated rapidly from 5 minutes after the initiation of CPR by EMS. The presence of witnesses and bystander-witnessed CPR may be factors that contribute to improved outcomes, but the effects were not remarkable. As another approach to reduce deaths due to choking, citizen education for the prevention of choking may be effective.

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

AimThe coronavirus disease (COVID-19) pandemic has negatively affected access to healthcare and treatment. This study aimed to explore the impact of the COVID-19 pandemic on older adults with out-of-hospital cardiac arrest (OHCA) in Japan, a country with a super-aging society. MethodsThis secondary analysis of the All-Japan Utstein Registry included patients aged 65 years and older with bystander-witnessed OHCA between January 1, 2005, and December 31, 2020. Survival outcomes were compared by time period using multivariable logistic regression analyses. The primary outcome measured was the one-month survival rate with neurologically favorable outcomes. ResultsBefore the COVID-19 pandemic, survival outcomes were steadily improving, and 32,024 patients in 2019 and 31,894 in 2020 were eligible for analysis. The proportions of conventional cardiopulmonary resuscitation and shock by public-access automated external defibrillators were lower in 2020 than in 2019 (6.7% versus 5.7%, p < 0.001 and 2.5% versus 2.1%, p < 0.001, respectively). Compared to 2019, the one-month survival after OHCA and prehospital return of spontaneous circulation decreased significantly in 2020 than in 2019 (7.7% versus 6.6%, adjusted odds ratio [AOR]: 0.88, 95% confidence interval [CI]: 0.83–0.94, and 16.8% versus 14.9%, AOR: 0.87, 95% CI: 0.83–0.91, respectively). The proportion of neurologically favorable outcomes also decreased, but the decrease was not statistically significant (3.4% versus 2.8%, AOR: 0.92, 95% CI: 0.83–1.01). ConclusionIn this population-focused, bystander-witnessed study regarding OHCA, the analysis of nationwide registry data revealed that the COVID-19 pandemic was associated with reduced survival among older adults with OHCA in Japan.

Short-term exposure to ambient fine particulate matter and out-of-hospital cardiac arrest: a nationwide case-crossover study in Japan

PM2·5 is an important but modifiable environmental risk factor, not only for pulmonary diseases and cancers, but for cardiovascular health. However, the evidence regarding the association between air pollution and acute cardiac events, such as out-of-hospital cardiac arrest (OHCA), is inconsistent, especially at concentrations lower than the WHO daily guideline (25 μg/m3). This study aimed to determine the associations between exposure to ambient air pollution and the incidence of OHCA. In this nationwide case-crossover study, we linked prospectively collected population-based registry data for OHCA in Japan from Jan 1, 2014, to Dec 31, 2015, with daily PM2·5, carbon monoxide (CO), nitrogen dioxide (NO2), photochemical oxidants (Ox), and sulphur dioxide (SO2) exposure on the day of the arrest (lag 0) or 1-3 days before the arrest (lags 1-3), as well as the moving average across days 0-1 and days 0-3. Daily exposure was calculated by averaging the measurements from all PM2·5 monitoring stations in the same prefecture. The effect of PM2·5 on risk of all-cause or cardiac OHCA was estimated using a time-stratified case-crossover design coupled with conditional logistic regression analysis, adjusted for daily temperature and relative humidity. Single-pollutant models were also investigated for the individual gaseous pollutants (CO, NO2, Ox, and SO2), as well as two-pollutant models for PM2·5 with these gaseous pollutants. Subgroup analyses were done by sex and age. Over the 2 years, 249 372 OHCAs were identified, with 149 838 (60·1%) presumed of cardiac origin. The median daily PM2·5 was 11·98 μg/m3 (IQR 8·13-17·44). Each 10 μg/m3 increase in PM2·5 was associated with increased risk of all-cause OHCA on the same day (odds ratio [OR] 1·016, 95% CI 1·009-1·023) and at lags of up to 3 days, ranging from OR 1·015 (1·008-1·022) at lag 1 to 1·033 (1·023-1·043) at lag 0-3. Results for cardiac OHCA were similar (ORs ranging from 1·016 [1·007-1·025] at lags 1 and 2 to 1·034 [1·021-1·047] at lag 0-3). Patients older than 65 years were more susceptible to PM2·5 exposure than younger age groups but no sex differences were identified. CO, Ox, and SO2 were also positively associated with OHCA while NO2 was not. However, in two-pollutant models of PM2·5 and gaseous pollutants, only PM2·5 (positive association) and NO2 (negative association) were independently associated with increased risk of OHCA. Short-term exposure to PM2·5 was associated with an increased risk of OHCA even at relatively low concentrations. Regulatory standards and targets need to incorporate the potential health gains from continual air quality improvement even in locations already meeting WHO standards. None.

Abstract 323: Time to Specialized Prehospital Care and Neurologically Favorable Survival After Traumatic Out-Of-Hospital Cardiac Arrest: Results From a Japanese Registry-Based Study

Introduction: Specialized care is essential for successful resuscitation after traumatic out-of-hospital cardiac arrest (OHCA). However, the effect of early specialized care by healthcare professional for traumatic OHCA in the prehospital setting is unknown. Hypothesis: We sought to determine whether time to specialized prehospital care by healthcare professional is associated with a neurological status after traumatic OHCA. Methods: This was a nationwide population-based study of traumatic OHCA based on data from the All-Japan Utstein Registry. We included patients who experienced traumatic OHCA in Japan from 2013 to 2016. The primary outcome was 1-month neurologically favorable survival. Results: A total of 8,470 patients were included. Among these patients, 50 (0.6%) survived with a favorable neurological status one month after OHCA. The median time to specialized prehospital care by healthcare professional was 9 minutes (IQR, 7-13; mean [SD], 10.7 [6.3] minutes). Longer time to specialized prehospital care was associated with a decreased chance of neurologically favorable survival: 2.6, 1.2, 0.9, 0.5, 0.2, and 0.0%, respectively, when time to specialized prehospital care was treated as a categorical variable categorized into ≤2, 3-5, 6-8, 9-11, 12-14, and ≥15 minutes (P for trend &lt;0.0001), and multivariable-adjusted OR per minute delay 0.79 (95%CI 0.70-0.89, P&lt;0.0001) when time to specialized prehospital care was treated as a linear and continuous variable. In subgroup analyses, longer time to specialized care was associated with a decreased chance of neurologically favorable survival when ALS was provided in the prehospital setting (adjusted OR 0.73, 95%CI 0.61-0.87, P=0.0007), especially when prehospital ALS was performed by physician (adjusted OR 0.72, 95%CI 0.56-0.93, P=0.0119), whereas there was no significant association between time to specialized care and neurologically favorable survival when only BLS was provided in the prehospital setting (adjusted OR 0.86, 95%CI 0.74-1.01, P=0.0734). Conclusion: In traumatic OHCA, delayed specialized prehospital care by healthcare professional was associated with a decreased chance of neurologically favorable survival, especially when a physician was involved in prehospital ALS.

1271Short-term effects of exposure to ambient fine particulate matter on out-of-hospital cardiac arrest: a nationwide case-crossover study in Japan

Abstract Introduction The cardiovascular health consequences of ambient air pollution generally equal or exceed those due to pulmonary diseases and cancers. Particulate matter less than 2.5μm in aerodynamic diameter (PM2.5) has become a major focus of research on the short-term exposure to air pollution and cardiovascular disease. However, the evidence regarding the association between several air pollutants and out-of-hospital cardiac arrest (OHCA), has been inconsistent, which could be due to limited sample sizes (∼11,000). Thus, a larger study may assist in characterising possible associations. Purpose This study aimed to identify the associations between exposure to ambient air pollution and the incidence of OHCA in Japan. Methods A case-crossover design was used to determine the odds ratio (OR) of OHCA across Japan with daily exposure of PM2.5, carbon monoxide (CO), photochemical oxidants (Ox), and sulfur dioxide (SO2) on the day of the arrest or 1–3 days before it (lag 0–3). OHCA cases were identified through the All-Japan Utstein registry of the Fire and Disaster Management Agency from January 1, 2014 to December 31, 2015. All cause OHCAs were investigated by conditional logistic regression adjusted for daily temperature and relative humidity. Results A total of 249,372 OHCAs were included during study period. Each 10 μg/m3 increase in daily PM2.5 exposure over 4 days was associated with all cause OHCA risk (lag 0: OR 1.017, 95% confidence interval (CI) 1.010, 1.024; lag 1: OR 1.015, 95% CI 1.008, 1.022; lag 2: OR 1.018, 95% CI 1.011, 1.025; lag 3: OR 1.021, 95% CI 1.014, 1.028; lag 0–1: OR 1.022, 95% CI 1.014, 1.030). CO, Ox and SO2 also showed significant associations with OHCAs. In the multi-pollutant model, the effects of PM2.5 remained independent of CO, Ox and SO2 (Table). Conclusion Short-term exposure to PM2.5 was independently associated with an increased risk of OHCA.

P1701Sex-related difference in receiving bystander cardiopulmonary resuscitation and clinical outcome among out-of-hospital cardiac arrest patients

Abstract Background Early studies from US and Europe have reported that female out-of-hospital cardiac arrest (OHCA) patients were less likely to receive bystander cardiopulmonary resuscitation (CPR). However, little is known about sex-related difference in receiving CPR and clinical outcome among adult OHCA patients in Japan. Methods This study was a nation-wide, population-based observational study of OHCA in Japan from 2011 to 2015. We included all adult cardiogenic OHCA patients. We excluded patients witnessed by emergency medical services (EMS) from the present analysis. To account for the age-related difference, we stratified by age category: 18–39, 40–64, 65–79, and ≥80. To examine the association between patient sex and neurological outcome at 30-day, we fitted multivariable logistic regression model with adjustment for age, bystander CPR status, first document rhythm, dispatcher instruction and EMS response time. Results There were 339,317 adult cardiogenic, not EMS-witnessed OHCA patients (median age, 80; female, 43.5%) in Japan from 2011 to 2015. Overall, 171,122 (50.4%) received CPR by citizen, 34,283 (10.1%) had initial shockable rhythm, and 11,421 (3.4%) had favorable neurological status at 30-day. Female patients were more likely to receive bystander CPR (vs. male; 53.8% vs. 47.8%), and were less likely to have initial shockable rhythm (5.2% vs. 13.9%) and favorable neurological status at 30-day (1.8% vs. 4.6%) (all; p&lt;0.001). With stratification by age category, elderly female patients (aged ≥65) were more likely to received bystander CPR (P&lt;0.001), whereas male patients were more likely to received bystander CPR among patients aged &lt;40. Multivariable logistic regression analysis showed that female patients had a lower rate of favorable neurological status at 30-day, compared to male patients in all age categories (all; P&lt;0.05). Sex difference in bystander CPR Overall Male (n=191,672) Female (n=147,645) p-value All (n=339,317) 50.4% 47.8% 53.8% &lt;0.001 Aged 18–39 (n=6,216) 56.0% 56.9% 53.5% 0.02 Aged 40–64 (n=50,320) 48.5% 48.5% 48.3% 0.69 Aged 65–80 (n=105,141) 46.5% 45.5% 48.3% &lt;0.001 Aged ≥80 (n=177,640) 53.2% 49.0% 56.7% &lt;0.001 OR for neurological outcome at 30-day Conclusion Unlike the situation in Europe and US, female OHCA patients, especially elderly female, were more likely to receive bystander CPR in Japan. However, female patients had worse clinical outcome after OHCA. Further investigations including in-hospital treatment are needed to clarify the sex-difference in clinical outcome after OHCA. Acknowledgement/Funding None

2284Sex and age differences in short-term exposure to ambient fine particulate matter and out-of-hospital cardiac arrest: a nationwide case-crossover study in Japan

Abstract Introduction Accumulating evidence has shown the elevated risk for cardiovascular diseases (CVD) with exposure to air pollution, such as fine particles &lt;2.5μm in aerodynamic diameter (PM2.5). A bi-directional relationship exists between air pollution and traditional CV risk factors like obesity, diabetes, and hypertension. However, little is known about the effect of age and sex on association between ambient air pollution and out-of-hospital cardiac arrest (OHCA). Purpose This study aimed to identify sex and age differences in the associations between exposure to PM2.5 and OHCA in Japan. Methods A case-crossover design was used to determine the odds ratio (OR) of OHCA across Japan with daily PM2.5 exposure on the day of the arrest or 1–3 days before it (lag 0–3). OHCA cases were identified through the All-Japan Utstein registry of the Fire and Disaster Management Agency from January 1, 2014 to December 31, 2015. OHCAs were investigated by conditional logistic regression adjusted for daily temperature and relative humidity with stratification by sex and age. Results A total of 249,372 OHCAs were included during study period. Their mean age was 75 years and 57% were male. Each 10 μg/m3 increase in daily PM2.5 exposure over 4 days was associated with all cause OHCA risk for male (lag 0: OR 1.022, 95% confidence interval (CI) 1.013, 1.031; lag 1: OR 1.016, 95% CI 1.007, 1.025; lag 2: OR 1.016, 95% CI 1.007, 1.026; lag 3: OR 1.017, 95% CI 1.008, 1.027; lag 0–1: OR 1.025, 95% CI 1.015, 1.036). Increased risk in OHCA was also found with lag 1 to lag 3 PM2.5 exposure among women. Lag 0 to lag 3 PM2.5 exposures were significantly associated with OHCA among patients older than 65 years. Among 35 to 64 years, only lag 3 PM2.5 exposure was associated with an increased risk in OHCA. No significant association was observed between PM2.5 exposure and OHCA among patients less than 35 years. Conclusions Short-term exposure to PM2.5 is associated with an increased risk of OHCA in both sexes. Patients older than 65 years were more susceptible to PM2.5 exposure than younger age group.

Public location and survival from out-of-hospital cardiac arrest in the public-access defibrillation era in Japan

BackgroundThe use of public-access automated external defibrillators (AEDs) has become common in Japan. To provide a strategy for appropriate public-access AED deployment, we assessed public-access defibrillation (PAD) by laypersons and the outcomes following out-of-hospital cardiac arrest (OHCA) among adult patients by location of arrest. MethodsFrom a nationwide, prospective, population-based registry of patients after OHCA in Japan, we enrolled adult patients with bystander-witnessed OHCA of medical origin in public locations between 2013 and 2015. The primary outcome measure was one-month favorable neurological outcome defined by cerebral performance category 1 or 2. Factors associated with favorable neurological outcome after ventricular fibrillation (VF) were assessed by multivariable logistic regression analysis. ResultsA total of 20,970 adult bystander-witnessed OHCAs of medical origin occurred in public locations. Of those, the proportions of PAD by location were: 13.1% (757/5761) in public areas, 15.9% (333/2089) at workplaces, 26.0% (544/2095) in recreation/sports areas, 36.1% (112/310) in educational institutions, and 5.8% (241/4151) on streets/highways. In a multivariable analysis of VF arrests, both bystander cardiopulmonary resuscitation [adjusted odds ratio (AOR), 1.78; 95% confidence interval (CI), 1.54–2.07] and PAD (AOR, 2.33; 95% CI, 2.05–2.66), and emergency medical service (EMS) response time (AOR, 0.89; 95% CI, 0.87–0.90) were associated with improved outcomes. Earlier PAD initiated by bystanders before EMS arrival was also associated with better outcomes after OHCA. ConclusionsIn Japan, where public-access AEDs are well-disseminated, the PAD program worked effectively for adult OHCA of medical origin occurring in public locations. Notably, the proportions of PAD differed substantially according to specific public locations.

Impact of the consumption tax rate increase on out-of-hospital cardiac arrest in Japan: an interrupted time series analysis

ObjectivesThe Japanese government increased the consumption tax rate from 5% to 8% on 1 April 2014. The impact of this policy on the incidence of out-of-hospital cardiac arrest (OHCA) is...

Abstract 284: Association of Neurological Outcome and Survival With Interventions by Bystander and Emergency Medical Service for Unwitnessed Out-of-Hospital Cardiac Arrest Patient; Results From the JCS-ReSS Study

Introduction: Although studies have shown that bystander cardiopulmonary resuscitation (CPR) in witnessed out-of-hospital cardiac arrest (OHCA) is associated with better neurological prognosis, whether bystander and Emergency Medical Service (EMS) interventions are associated with prognosis in unwitnessed OHCA patients is not fully elucidated. We aimed to investigate the prognostic importance of bystander and EMS interventions among unwitnessed OHCA patients in Japan. Methods and Results: This study was a nation-wide population-based observational study of OHCA in Japan from 2011 to 2015 based on data from the All-Japan Utstein Registry. The outcome measures were neurological outcome and survival at 30-day. The neurologically favorable outcome was defined as Glasgow-Pittsburgh cerebral performance category score 1 or 2. First, to investigate the effectiveness of bystander interventions, we included 105,655 unwitnessed cardiogenic OHCA patients (aged 18-80 years). Of these, 1,614 (1.5%) showed neurologically favorable outcome and 3,273 (3.1%) survived at 30-day. Multivariate logistic regression analysis adjusting for age, sex, geographical region, year and EMS response time showed that bystander CPR was associated with neurologically favorable outcome (adjusted odds ratio [aOR] 1.49, 95% CI 1.35-1.65, P&lt;0.001). Additionally, to investigate the effectiveness of EMS interventions for patients with non-shockable rhythm, we examined 43,342 patients who were performed public CPR and had the initial rhythm of pulseless electrical activity (PEA) or asystole. Of these, 101 (0.2%) showed neurologically favorable outcome and 453 (1.0%) were survival at 30-day. Advanced airway management by EMS was negatively associated with neurologically favorable outcome (aOR 0.55, 95% CI 0.37-0.81, P=0.003) and administration of epinephrine by EMS was associated with survival (aOR 2.35, 95% CI 1.89-2.92, P&lt;0.001). Conclusions: Among unwitnessed OHCA patients, bystander CPR was associated with neurologically favorable prognosis. For unwitnessed OHCA patients with non-shockable rhythm, epinephrine administration was associated with survival, but advanced airway management was negatively associated with neurological outcome.

Time to epinephrine and survival after paediatric out-of-hospital cardiac arrest.

Delay in administration of epinephrine is associated with decreased survival among children with in-hospital cardiac arrest with an initial non-shockable rhythm. Whether this association is applicable to paediatric out-of-hospital cardiac arrest (OHCA) population remains unknown. We aimed to determine whether time to epinephrine administration is associated with outcomes in paediatric OHCA. This was a nation-wide population-based study of paediatric OHCA in Japan from 2005 to 2012 based on data from the All-Japan Utstein Registry. We included paediatric OHCA patients (aged between 1 and 17 years) who received at least one dose of epinephrine. The primary outcome was 30-day survival. A total of 225 patients were included in the final cohort. Among the 225 patients, 23 (10.2%) survived 30 days after OHCA. The median time from emergency call to first epinephrine administration was 26 min [interquartile range, 20-32; range, 9-128; mean (standard deviation), 28.7 (15.5) min]. Longer time to epinephrine administration was associated with decreased chance of survival: 50.0, 41.2, 13.0, 11.6, 3.9, and 3.1%, respectively, when time to epinephrine was treated as a categorical variable categorized into ≤10, 11-15, 16-20, 21-25, 26-30, or > 30 min (P for trend <0.0001), and adjusted odds ratio 0.90 (95% confidence interval 0.82-0.96, P = 0.0011) when time to epinephrine was treated as a linear and continuous variable in a multivariable logistic regression model. Similar trends were observed for prehospital return of spontaneous circulation (P = 0.0032) and neurologically favourable survival (P = 0.0014). Among paediatric OHCA patients, delayed administration of epinephrine was associated with a decreased chance of favourable outcomes.

Age × Gender Interaction Effect on Resuscitation Outcomes in Patients With Out-of-Hospital Cardiac Arrest

Although an interaction between gender and age has been shown to influence resuscitation outcomes in patients with out-of-hospital cardiac arrest (OHCA), this interaction has not been investigated in Asian populations. In this prospective, observational study, data from all cases of OHCA in Japan between 2005 and 2012 were obtained from the Japanese National Registry. We determined the relative excess risk due to interaction and the ratio of odds ratios (ORs) to assess the interaction effect of gender and age on the incidence of return of spontaneous circulation (ROSC) before hospital arrival, 1-month survival, and neurologically intact survival 1month after OHCA. Male gender was associated with decreased ROSC and lower 1-month survival rates in patients with OHCA of presumed cardiac origin. Older age was associated with lower 1-month and neurologically intact survival rates in male patients with OHCA of presumed cardiac and noncardiac origin and with increased ROSC in male patients with OHCA of presumed cardiac origin. The relative excess risk due to interaction for ROSC in patients with OHCA of presumed cardiac origin was statistically significant (OR 0.19, 95% confidence interval [CI] 0.06 to 0.32). The ratio of ORs for ROSC was statistically significant in patients with OHCA of presumed cardiac origin (OR 1.25, 95% CI 1.05 to 1.47) and of noncardiac origin (OR 0.40, 95% CI 0.17 to 0.92). In conclusion, the interaction effect between age and gender on ROSC was positive in OHCA cases of presumed cardiac origin and negative in those of noncardiac origin.

Effect of prehospital advanced airway management for pediatric out-of-hospital cardiac arrest

BackgroundRespiratory care may be important in pediatric out-of-hospital cardiac arrest (OHCA) due to the asphyxial nature of the majority of events. However, evidence of the effect of prehospital advanced airway management (AAM) for pediatric OHCA is scarce. MethodsThis was a nationwide population-based study of pediatric OHCA in Japan from 2011 to 2012 based on data from the All-Japan Utstein Registry. We included pediatric OHCA patients aged between 1 and 17 years old. The primary outcome was one-month neurologically favorable survival defined as a Glasgow-Pittsburgh cerebral performance category (CPC) score of 1–2 (corresponding to a Pediatric CPC score of 1–3). ResultsA total of 2157 patients were included in the final cohort; 365 received AAM and 1792 received bag-valve-mask (BVM) ventilation only. Among the 2157 patients, 213 (9.9%) survived with favorable neurological outcomes (CPC of 1–2) one month after OHCA. There were no significant differences in neurologically favorable survival between the AAM and BVM groups after adjusting for potential confounders, although there was a tendency favoring BVM ventilation: propensity score matching, OR 0.74 (95%CI 0.35–1.59), and multivariable logistic regression modeling, ORadjusted 0.55 (95%CI 0.24–1.14). Subgroup analyses demonstrated that there were no subgroups in which AAM was associated with neurologically favorable survival, including the non-cardiac (primarily asphyxial) etiology group. ConclusionsIn pediatric OHCA, prehospital AAM was not associated with an increased chance of neurologically favorable survival compared with BVM-only ventilation. However, careful consideration is required to interpret the findings, as there may be unmeasured residual confounders and selection bias.

Public access defibrillation and outcomes after pediatric out-of-hospital cardiac arrest

BackgroundUse of automated external defibrillators (AEDs) has been recommended for pediatric out-of-hospital cardiac arrest (OHCA). However, there are no conclusive studies that elucidated the effectiveness of public-access defibrillation (PAD) in children. MethodsThis was a nationwide, population-based, propensity score-matched study of pediatric OHCA in Japan from 2011 to 2012, based on data from the All-Japan Utstein Registry. We included pediatric OHCA patients (aged 1–17 years) who received bystander cardiopulmonary resuscitation. The primary outcome was a favorable neurological state 1 month after OHCA (defined as a CPC score of 1–2). ResultsA total of 1193 patients were included in the final cohort; 57 received PAD and 1136 did not. Among 1193 patients, 188 (15.8%) survived with a favorable neurological status 1 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, ORadjusted 5.10 (95% CI 2.01–13.70). Similar findings were observed for the secondary outcomes (i.e., neurologically favorable survival with a CPC score of 1, one-month survival, and prehospital return of spontaneous circulation). In subgroup analyses, there were no significant differences in neurologically favorable survival between the PAD group and non-PAD group in the unwitnessed cohort (ORadjusted 7.76 [0.75–81.90]) or the non-cardiac etiology cohort (ORadjusted 6.65 [0.64–66.24]). ConclusionsPAD was associated with an increased chance of neurologically favorable survival in pediatric OHCA (aged 1–17 years) who received bystander CPR, except for in cases of unwitnessed or non-cardiac etiology.

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 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 &lt; 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.

Patient Characteristics and Outcomes of Extracorporeal Cardiopulmonary Resuscitation (ECPR) for Adult Non-traumatic Out-of-hospital Cardiac Arrest (OHCA) versus Non-ECPR – A community-wide evaluation

between patients treated with ALS and BLS. Main outcome measures were functional status at 1 month after OHCA (good status defined as cerebral performance category 1 or 2, and poor as 3 or 4). Results: Of the eligible 158,991 patients, 148,230 (93.2%) were received ALS and 10,761 (6.8%) were received BLS. The propensityscore matching process selected 10,736 patients each from ALS and BLS group. Compared with BLS group, ALS group incurred a higher rate of return of spontaneous circulation before hospital arrival (8.6% vs. 6.2%) and poor functional status (3.4% vs. 2.5%), a similar survival rate (5.1% vs. 5.3%), and a lower rate of good functional status (1.7%vs. 2.8%). Inmultivariable logistic regression, ALS was associated with decreased odds of good functional status (odds ratio [OR] 0.56, 95% CI 0.42–0.74) and increased odds of poor functional status (OR 1.25, 95% CI 1.03–1.50). Adrenaline administration was also associated with decreased odds of good functional status (OR 0.41, 95% CI 0.25–0.67), meanwhile, no association was observedbetweenadvancedairway insertionand functional status. Conclusions: Among adult patients with OHCA in Japan, ALS was negatively associated with good functional status and increased the chance of poor functional survival compared with BLS.

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 …

Managing the Airway During Cardiac Arrest

FOR DECADES, AN AXIOM OF CARE IN THE RESUSCITATION of cardiopulmonary arrest was “airway first.” Airway management seeks to maintain or create an open pathway to the lungs to ensure adequate oxygenation and ventilation, commonly using the strategy of bag-valve-mask ventilation. However, because maintaining an open pathway for gas exchange is difficult with this approach and does not protect the lungs from aspiration of gastric contents, more advanced airway maneuvers are often used. These techniques usually involve endotracheal intubation or supraglottic airway placement. The latter device is inserted blindly through the mouth, sealing the hypopharynx to facilitate oxygen delivery without a direct conduit through the glottis. Paralleling practice in the hospital, most emergency medical services systems in North America prioritize the use of advanced airways (endotracheal intubation or a supraglottic airway). In this issue of JAMA, the study by Hasegawa et al examines 2 advanced airway management approaches in the treatment of patients with out-of-hospital cardiac arrest. Out-of-hospital airway management in North America started with paramedics using ineffective, blindly inserted devices, notably the esophageal-obturator airway. In the 1970s, demonstration projects in Pittsburgh, Pennsylvania, Columbus, Ohio, San Diego, California, and Boston, Massachusetts, provided the impetus to encourage wide use of paramedic endotracheal intubation. The initial demonstration projects of paramedic intubation were designed to evaluate the feasibility of the concept—there were few follow-up studies to verify the safety or effectiveness of the technique. Despite these limited data, early paramedic intubation became a centerpiece of out-of-hospital care for treatment of cardiac arrest. Over the last 5 years, emergency medical services personnel have experimented with initial supraglottic airway insertion rather than intubation to minimize interruptions in cardiopulmonary resuscitation chest compressions. Recent studies have questioned the wisdom of the wide use of out-of-hospital endotracheal intubation in many severely ill or injured patients. Out-of-hospital endotracheal intubation adverse events include unrecognized esophageal placement, tube dislodgement, iatrogenic hypoxia and bradycardia, and frequent need for multiple tube insertion attempts. Endotracheal intubation during cardiac arrest can interfere with cardiopulmonary resuscitation continuity of chest compression or facilitate inadvertent hyperventilation, both of which can adversely influence cardiac arrest survival. Out-of-hospital endotracheal intubation has added pragmatic constraints. Intubation is a difficult technique, requiring mastery of motor skills and decision making. Paramedics deliver this care in uncontrolled settings; while paramedic students seek to learn intubation under the mentorship of anesthesiologists in the operating room, access to this controlled learning setting is limited. Many paramedic students complete their training with little exposure to live endotracheal intubation. Also limiting advanced airway skills is usual practice, in which endotracheal intubation opportunities can be sparse, further affecting the effectiveness when needed. For instance, in Pennsylvania, paramedics perform a median of 1 endotracheal intubation per year. Complicating matters are recent studies that fail to demonstrate a benefit of paramedic endotracheal intubation in traumatic brain-injured or cardiac arrest cohorts. Although the use of supraglottic airway devices was intended to circumvent many of the adverse effects of endotracheal intubation, a recent animal study suggests potential neurologic harm from use of these devices. In the current study involving 649 654 adults with out-ofhospital cardiac arrest in Japan, Hasegawa et al observed that 30-day neurologically favorable survival was higher among those who received bag-valve-mask ventilation alone (2.9% among 367 837 patients) compared with those who received endotracheal intubation (1.0% among 41 972 patients) or supraglottic airway insertion (1.1% among 239 550 patients). This natural experiment from the All-Japan Utstein Registry has several strengths, including a diverse national enrollment, important functional assessment of those treated, and use of propensity score matching to help address selection bias. Although not the first report to suggest higher survival with basic bag-valve-mask ventilation, the study is large, methodologically rigorous, and compelling.