Out-of-hospital Cardiac Arrest Of Presumed Cardiac Etiology Research Articles

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

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

Improved phenotyping of cardiogenic shock after out-of-hospital cardiac arrest

Abstract Background Cardiogenic shock (CS) is an important cause of mortality after out-of-hospital cardiac arrest (OHCA). The SCAI classification is a simple grading system to reflect the spectrum of CS but fails to reflect phenotypes of CS based on haemodyamic/haemometabolic criteria [1,2]. Purpose We applied the SCAI grade and features of tissue hypoperfusion (i.e., elevated lactate) to develop a phenotypic classification of CS after resuscitated OHCA of cardiac aetiology and evaluate its association with outcome. Methods Patients with resuscitated OHCA of presumed cardiac aetiology were included in the King’s Out-of-hospital Cardiac Arrest Registry (KOCAR), and Uniwersyteckie Centrum Kliniczne w Gdańsku, Poland (UCK) between 1st May 2012 and 31st December 2020. Patients were classified into phenotypes of CS according to a combination of SCAI grade and lactate concentration on arrival at the hospital. Patients were then placed into one of 4 groups - those with SCAI grades A-B, i.e., no CS, were termed non-shocked if lactate <5, hypoperfusion group if lactate ≥5. Amongst those with CS (SCAI grades C-E), those with lactate <5 were considered to be in haemodynamic shock, and those with lactate ≥5 were in haemometabolic shock (Figure 1). The primary endpoint was mortality and cause of death at hospital discharge. Amongst surviving patients, the neurological outcome was defined by the Cerebral Performance Category (CPC) score. Results Of 627 patients (median age 62.9 ± 20.7, and 76.4% male), 218 patients (34.8%) were classified as non-shocked, 116 (18.5%) as hypoperfused, 106 (16.9%) as haemodynamic shock, and 187 (29.8%) as haemometabolic shock. Low flow time increased as the shock classification deteriorated, with the shortest time in the non-shocked group and the longest in the haemometabolic shock group (p <0.001). There were lower rates of initial shockable rhythm in haemometabolic shock followed by hypoperfused patients (p <0.001) and higher rates of adrenaline use in these groups (p< 0.001). Survival with good neurological outcome was most common in the non-shocked, then in haemodynamic shock groups, followed by the hypoperfusion group and with significantly less favourable survival in the haemometabolic shock group CS (Table 1; Figure 1; p<0.001). Modes of death differed significantly by shock classification group. Patients in the non-shock and hypoperfusion groups had low rates of cardiac multiple organ dysfunction syndrome (MODS) death, with the highest rates of neurological death seen amongst the hypoperfused group (35.7%). Patients in the haemodynamic shock group had substantially higher cardiac death rates, and those in the haemometabolic shock group had the highest cardiac and MODS death rates. Conclusion A classification based on SCAI grade and lactate levels identifies distinct phenotypes of CS after OHCA and may identify specific sub-groups for selection of mechanical circulatory support devices.Table 1Figure 1

Association between the COVID-19 pandemic in 2020 and out-of-hospital cardiac arrest outcomes and bystander resuscitation efforts for working-age individuals in Japan: a nationwide observational and epidemiological analysis

BackgroundImproving out-of-hospital cardiac arrest (OHCA) prognosis within the working-age population is important, but no studies have investigated the effects of COVID-19 pandemic specifically on the working-age population with OHCAs. We...

Machine learning analysis to identify data entry errors in prehospital patient care reports: a case study of a national out-of-hospital cardiac arrest registry

Background: To develop and validate machine learning models for data entry error detection in a national out-of-hospital cardiac arrest (OHCA) prehospital patient care report database. Methods: Adult OHCAs of presumed cardiac etiology were included. Data entry errors were defined as discrepancies between the coded data and the free-text note documenting the intervention or event; for example, information that was recorded as “absent” in the coded data but “present” in the free-text note. Machine learning models using the extreme gradient boosting, logistic regression, extreme gradient boosting outlier detection, and K-nearest neighbor outlier detection algorithms for error detection within nine core variables were developed and then validated for each variable. Results: Among 12,100 OHCAs, the proportion of cases with at least one error type was 16.2%. The area under the receiver operating characteristic curve (AUC) of the best-performing model (model with the highest AUC for each outcome variable) was 0.71–0.95. Machine learning models detected errors most efficiently for outcome place and initial rhythm errors; 82.6% of place errors and 93.8% of initial rhythm errors could be detected while checking 11% and 35% of data, respectively, compared to the strategy of checking all data. Conclusion: Machine learning models can detect data entry errors in care reports of EMS clincians with acceptable performance and likely can improve the efficiency of the process of data quality control. EMS organizations that provide more prehospital interventions for OHCA patients could have higher error rates and may benefit from the adoption of error-detection models.

Extracorporeal cardiopulmonary resuscitation in adult patients with out-of-hospital cardiac arrest: a retrospective large cohort multicenter study in Japan

BackgroundThe prevalence of extracorporeal cardiopulmonary resuscitation (ECPR) in patients with out-of-hospital cardiac arrest (OHCA) has been increasing rapidly worldwide. However, guidelines or clinical studies do not provide sufficient data on ECPR practice. The aim of this study was to provide real-world data on ECPR for patients with OHCA, including details of complications.MethodsWe did a retrospective database analysis of observational multicenter cohort study in Japan. Adult patients with OHCA of presumed cardiac etiology who received ECPR between 2013 and 2018 were included. The primary outcome was favorable neurological outcome at hospital discharge, defined as a cerebral performance category of 1 or 2.ResultsA total of 1644 patients with OHCA were included in this study. The patient age was 18–93 years (median: 60 years). Shockable rhythm in the initial cardiac rhythm at the scene was 69.4%. The median estimated low flow time was 55 min (interquartile range: 45–66 min). Favorable neurological outcome at hospital discharge was observed in 14.1% of patients, and the rate of survival to hospital discharge was 27.2%. The proportions of favorable neurological outcome at hospital discharge in terms of shockable rhythm, pulseless electrical activity, and asystole were 16.7%, 9.2%, and 3.9%, respectively. Complications were observed during ECPR in 32.7% of patients, and the most common complication was bleeding, with the rates of cannulation site bleeding and other types of hemorrhage at 16.4% and 8.5%, respectively.ConclusionsIn this large cohort, data on the ECPR of 1644 patients with OHCA show that the proportion of favorable neurological outcomes at hospital discharge was 14.1%, survival rate at hospital discharge was 27.2%, and complications were observed during ECPR in 32.7%.

Abstract 9086: Sex Differences in the Association Between Bystander CPR and Survival for Patients With Out-of-Hospital Cardiac Arrest

Background: Bystander cardiopulmonary resuscitation (CPR) is associated with a better survival outcome in patients with out-of-hospital cardiac arrest (OHCA). However, there may be cultural barriers in performing high-quality bystander CPR in women in some non-Western countries and the effect of bystander CPR on survival outcomes may differ by patients’ sex. Methods: Using data between 2012-2018 from a national OHCA registry from the Republic of Korea, we identified adult patients with OHCA of presumed cardiac etiology. The main exposures were bystander CPR and patients’ sex. The primary outcome was survival discharge and the secondary outcome was favorable neurological survival. Multivariable logistic regression evaluated the association between bystander CPR and survival, adjusted for patients’ age, sex, socio-economic status, year of arrest, witnessed arrest status, initial OHCA rhythm, location of arrest, urbanization level of arrest location, and type of bystander. The interaction between bystander CPR and sex was explicitly evaluated in the models. Results: Of 101,505 patients with OHCA in the cohort, 34,124 (33.6 %) were women and 67,381 (64.4 %) were men. Bystander CPR was performed on 18,481 (54.2%) women and 35,904 (53.3%) men (p=0.07). Unadjusted rates of survival discharge were 4.5% in women and 9.5 % in men (p<0.001), and rates of favorable neurological survival were 2.5% in women and 6.4% in men (p<0.001). In multivariable logistic regression models, there was a significant interaction (p=0.005) between bystander CPR and sex for survival to discharge, with an adjusted OR for bystander CPR of 1.16 (95% CI: 1.08-1.23) in men and 0.91 (95% CI: 0.80-1.02) in women. For favorable neurological survival, there was also a significant interaction (p=0.01) between sex and bystander CPR, with an adjusted OR for bystander CPR of 1.47 (95% CI: 1.36-1.60) in men and 1.16 (95% CI: 0.98- 1.37) in women. Conclusions: In a national registry of OHCA from the Republic of Korea, men who received bystander CPR were more likely to survive whereas women who received bystander CPR were not.

Outcomes of patients with OHCA of presumed cardiac etiology that did not achieve prehospital restoration of spontaneous circulation: The All-Japan Utstein Registry experience

BackgroundCorrect identification of futile prehospital resuscitation for out-of-hospital cardiac arrest (OHCA) may reduce unnecessary transports. Prehospital return of spontaneous circulation (ROSC) is considered by many to be an important predictor of outcome. The purpose of this study was to evaluate OHCA victims without prehospital ROSC characteristics and their outcomes in relation to the universal Termination of Resuscitation (TOR) rule. MethodsA retrospective, population-based review of OHCA victims without prehospital ROSC from January 1, 2010 to December 31, 2017 in the All-Japan Utstein Registry. We compared those that met the universal TOR rule and those that did not for the primary outcome: one-month survival with neurologically favorable Cerebral Performance Category (CPC) 1 or 2. Results989,929 OHCA cases, 18 years of age or older, were registered in the All-Japan Utstein Registry and 525,801 cases were of presumed cardiac origin and had no prehospital ROSC. Of these, the one-month CPC was 1 or 2 for 3957 cases (0.8%). In the ‘no ROSC’ group who also met the TOR rule, the number of cases was 433,571 with a one-month survival of 0.9% (3799 cases), and the proportion with a CPC 1or 2 was 0.2% (699 cases). ConclusionsContinued resuscitation and transport of cases with no field ROSC who fulfill the TOR rule is futile and could be considered for adoption in Japan.

Daytime admission is associated with higher 1-month survival for pediatric out-of-hospital cardiac arrest: Analysis of a nationwide multicenter observational study in Japan.

Hospital characteristics, such as hospital type and admission time, have been reported to be associated with survival in adult out-of-hospital cardiac arrest (OHCA) patients. However, findings regarding the effects of hospital types on pediatric OHCA patients have been limited. The aim of this study was to analyze the relationship between the hospital characteristics and the outcomes of pediatric OHCA patients. This study was a retrospective secondary analysis of the Japanese Association for Acute Medicine-out-of-hospital cardiac arrest registry. The period of this study was from 1 June 2014 to 31 December 2015. We enrolled all pediatric patients (those 0-17 years of age) experiencing OHCA in this study. We enrolled all types of OHCA. The primary outcome of this study was 1-month survival after the onset of cardiac arrest. We analyzed 310 pediatric patients (those 0-17 years of age) with OHCA. In survivors, the rate of witnessed arrest and daytime admission was significantly higher than nonsurvivors (56% vs. 28%, p < 0.001: 49% vs. 31%; p = 0.03, respectively). The multiple logistic regression model showed that daytime admission was related to 1-month survival (odds ratio, OR: 95% confidence interval, CI, 3.64: 1.23-10.80) (p = 0.02). OHCA of presumed cardiac etiology and witnessed OHCA were associated with higher 1-month survival. (OR: 95% CI, 3.92: 1.23-12.47, and 6.25: 1.98-19.74, respectively). Further analyses based on the time of admission showed that there were no significant differences in the proportions of patients with witnessed arrest and who received bystander cardiopulmonary resuscitation and emergency medical service response time by admission time. Pediatric OHCA patients who were admitted during the day had a higher 1-month survival rate after cardiac arrest than patients who were admitted at night.

Association between admission to a cardiac arrest centre and survival to hospital discharge for adults following out-of-hospital cardiac arrest: A multi-centre observational study

AimThis study examined the association between admission to a cardiac arrest centre and survival to hospital discharge for adults following out-of-hospital cardiac arrest (OHCA). MethodsWe undertook a multicentre retrospective observational study of patients transferred to hospital after OHCA of presumed cardiac aetiology in three ambulance services in England. We used propensity score matching to compare rates of survival to hospital discharge in patients admitted to OHCA centres (defined as either 24/7 PPCI availability or >100 OHCA admissions per year) to rates of survival of patients admitted to non-centres. ResultsBetween January 2017 and December 2018, 10,650 patients with OHCA were included in the analysis. After propensity score matching, admission to a hospital with 24/7 PPCI availability or a high volume centre was associated with an absolute improvement in survival to hospital discharge of 2.5% and 2.8%, respectively. The corresponding odds ratios and 95% confidence intervals were 1.69 (1.28–2.23) and 1.41 (1.14–1.75), respectively. The results were similar when missing values were imputed. In subgroup analyses, the association between admission to an OHCA centre and improved rates of survival was mainly seen in patients with OHCA due to shockable rhythms, with no or minimal potential benefit for patients with OHCA and asystole as first presenting rhythm. ConclusionFollowing OHCA, admission to a cardiac arrest centre is associated with a moderate improvement in survival to hospital discharge. A corresponding bypass policy would need to consider the resulting increased workload for OHCA centres.

Effect of prehospital intraosseous combined with in-hospital intravenous access in out-of-hospital cardiac arrest

Objective: Obtaining vascular access during out-of-hospital cardiac arrest (OHCA) is challenging. The aim of this study was to compare the effectiveness of prehospital intraosseous infusion (IO) combined with in-hospital intravenous (IV) (pre-IO + in-IV) access versus the simple IV (pre-IV + in-IV) access in adult OHCA patients who do not achieve prehospital return of spontaneous circulation (ROSC). Methods: This retrospective observational study included adults with OHCA of presumed cardiac etiology between October 1, 2017-October 1, 2020 at an academic emergency department in China. All of the OHCA patients included within the study had Emergency Medical Services cardiopulmonary resuscitation and received prehospital epinephrine administration, but did not achieve prehospital ROSC. The study population were classified as either pre-IO + in-IV or IV (pre-IV + in-IV) based on their epinephrine administration route. The prehospital epinephrine routes were the first and only attempted route. The primary outcome investigated was sustained ROSC following arrival at the emergency department. The secondary outcome considered was the time from dispatch to the first epinephrine dose. Results: Of 193 included adult OHCA subjects who did not have prehospital ROSC, 128 received IV access only. The 65 pre-IO + in-IV-treated patients received epinephrine faster compared to IV-treated patients in terms of the median time from dispatch to the first injection of epinephrine (14.5 vs. 16.0 min, P = 0.001). In the pre-IO + in-IV group, 34 of 65 patients (52.3%) achieved sustained ROSC compared with 65 of 128 (50.8%) patients in the IV group (χ2 = 0.031, P = 0.841). There was no significant difference in sustained ROSC (adjusted OR1.049, 95% CI: 0.425-2.591, P = 0.918) between the two groups. Conclusion: A similar sustained ROSC rate was achieved for both the pre-IO + in-IV access group and the simple IV access group. Our results suggested that an IV route should be established quickly for prehospital IO-treated OHCA patients who do not achieve prehospital ROSC.

Long-term outcomes of adult out-of-hospital cardiac arrest in Queensland, Australia (2002–2014): incidence and temporal trends

ObjectiveTo describe annual incidence and temporal trends (2002–2014) in incidence of long-term outcomes of adult out-of-hospital cardiac arrest (OHCA) of presumed cardiac aetiology attended by Queensland Ambulance Service (QAS) paramedics,...

Shock Severity and Hospital Mortality In Out of Hospital Cardiac Arrest Patients Treated With Targeted Temperature Management.

Shock in patients resuscitated after out of hospital cardiac arrest (OHCA) is associated with an increased risk of mortality. We sought to determine the associations between lactate level, mean arterial pressure (MAP), and vasopressor/inotrope doses with mortality. Retrospective cohort study of adult patients with OHCA of presumed cardiac etiology treated with targeted temperature management (TTM) between December 2005 and September 2016. Multivariable logistic regression was performed to determine predictors of hospital death. Among 268 included patients, the median age was 64 (55, 71.8) years, including 27% females. OHCA was witnessed in 89%, OHCA rhythm was shockable in 87%, and bystander CPR was provided in 64%. Vasopressors were required during the first 24 h in 60%. Hospital mortality occurred in 104 (38.8%) patients. Higher initial lactate, peak Vasoactive-Inotropic Score (VIS), and lower mean 24-h MAP were associated with higher hospital mortality (all P < 0.001). After multivariable regression, both higher initial lactate (adjusted OR 1.15 per 1 mmol/L higher, 95% CI 1.00-1.31, P = 0.03) and higher peak VIS (adjusted OR 1.20 per 10 units higher, 95% CI 1.10-1.54, P = 0.003) were associated with higher hospital mortality, but mMAP was not (P = 0.92). However, patients with a mMAP < 70 mm Hg remained at higher risk of hospital mortality after multivariable adjustment (adjusted OR 9.30, 95% CI 1.39-62.02, P = 0.02). In patients treated with TTM after OHCA, greater shock severity, as reflected by higher lactate levels, mMAP < 70 mmHg, and higher vasopressor requirements during the first 24 h was associated with an increased rate of hospital mortality.

Age-specific trends in incidence and survival of out-of-hospital cardiac arrest from presumed cardiac cause in Denmark 2002–2014

BackgroundThe general cardiovascular health has improved throughout the last few decades for middle-aged and older individuals, but the incidence of several cardiovascular diseases is reported to increase in younger people. We aimed to assess the age-specific incidence and mortality rates associated with out-of-hospital-cardiac-arrest (OHCA) between 2002 and 2014. MethodsWe used the Danish Cardiac Arrest Register to identify patients with OHCA of presumed cardiac etiology. We calculated the annual incidence rates (IR) and 30-day mortality rates (MR) in 7 age groups (18–34 years, 35–44 years, 45–54 years, 55–64 years, 65–74 years, 75–84 years and ≥85 years, and ≤50 vs. >50 years). ResultsBetween 2002 and 2014, IR of OHCA decreased in individuals aged 65–74 and 75–84 years (158.08 to 111.2 and 237.5 to 217.09 per 100,000 person-years) and increased in the oldest from 201.01 to 325.4 pr. 100.000 person-years. In 18–34-years incidence of OHCA increased from 1.7 to 2.6 per 100.000 person-years. When stratifying into age ≤50 vs. >50 years, the IR deviated in those >50 years (from 117.8 in 2002 to 91 in 2008 to 117.4 in 2014100,000 person-years). The prevalence of acute myocardial infarction and heart failure prior to OHCA increased in the younger patient group in contrast to the older segment (AMI: ≤50 years: 10% to 16%, vs. >50 years: 25% to 23%, heart failure: ≤50 years 6% to 14%, vs. >50 years: 21% to 24%). ConclusionOver the last decades, incidence rates of OHCA decreased in individuals aged 65–84, but increased in individuals older than 85. An increase was also observed in younger individuals, potentially indicating a need for better cardiovascular disease prevention in younger adults.

Effects of moderate hypothermia versus normothermia on survival outcomes according to the initial body temperature in out-of-hospital cardiac patients: A nationwide observational study

AimWe aimed to investigate whether the effect of moderate hypothermia compared to normothermia on survival outcomes after out-of-hospital cardiac arrest (OHCA) patients who underwent targeted temperature management (TTM) differed between patients with and without initial spontaneous hypothermia. MethodsWe used data from a nationwide OHCA database collected between 2016 and 2017. Adult patients with OHCA of presumed cardiac aetiology who underwent TTM were included. Moderate hypothermia was defined as a target temperature of TTM < 35.5 °C. Initial hypothermia was defined as the measured temperature before starting TTM < 35.5 °C. Endpoints were survival to discharge and good neurological recovery (CPC 1 or 2). We compared outcomes between moderate hypothermia vs. normothermia using multivariable logistic regression with an interaction term between target temperature of TTM and initial spontaneous hypothermia. ResultsOf the 744 patients, 628 (84.4%) underwent moderate hypothermia. Initial spontaneous hypothermia was observed in 28.5% and 25.0% in the moderate hypothermia and normothermia groups, respectively. There was no significant difference in survival to discharge between moderate hypothermia and normothermia (57.2% vs 62.9%, p = 0.248). The initial spontaneous hypothermia group showed poorer survival than the initial non-hypothermia group (41.8% vs 64.4%, p < 0.001). In the interaction model, AOR (95% CI) for survival to discharge of moderate hypothermia was 3.51 (1.33–9.25) in patients with initial spontaneous hypothermia and 0.49 (0.27–0.89) in patients without initial spontaneous hypothermia. ConclusionThe effect of moderate hypothermia was modified by the initial temperature of OHCA survivors who underwent TTM. The positive effect of moderate hypothermia was increased in patients with initial spontaneous hypothermia.

Mechanical Chest Compression Device for Out-Of-Hospital Cardiac Arrest: A Nationwide Observational Study.

There are few studies on the use of a mechanical chest compression (meCC) device during transport in patients with out-of-hospital cardiac arrest (OHCA). The aim of our study was to compare the performance of an meCC device with that of manual chest compression during transport after OHCA. This study used data from the national cardiac arrest registry of patients with OHCA of presumed cardiac etiology. The primary exposure was the use of an meCC device by an Emergency Medical Services provider while transporting a patient to the emergency department. The primary endpoint was good cerebral performance category at discharge. We compared survival and neurologic outcomes between an meCC device group and a manual chest compression group. We also performed an interaction analysis to assess changes in study outcomes of meCC device use by the initial electrocardiogram (ECG) and transport time interval (TTI). Among 30,021 adult patients after OHCA with presumed cardiac etiology, an meCC device was used in 2357 (7.6%). After adjustment for possible confounders, there were no significant differences with respect to good neurologic recovery in the outcomes of patients who were treated with an meCC device and those who received manual chest compression (adjusted odds ratio [AOR] 0.66; 95% confidence interval [CI] 0.43-1.02) and survival to discharge (AOR 0.83; 95% CI 0.64-1.06). In the interaction model, the AOR of the meCC device study outcome did not interact with the initial ECG and TTI. The meCC device did not show better study outcomes than manual compression.

Does second EMS unit response time affect outcomes of OHCA in multi-tiered system? A nationwide observational study.

The time dependence of a multi-tier response for out-of-hospital cardiac arrest (OHCA) is unclear. The aim of this study was to evaluate the time-dependent effect of EMS response type in a multi-tiered system on the clinical outcomes of OHCA. Adult EMS-treated OHCA of presumed cardiac etiology who were not witnessed by EMS between January 2015 and December 2017 were included. The main exposure was EMS response type: single-tier response, early multi-tier response (0-18min from call to second EMS arrival), and late multi-tier response (19min from call to second EMS arrival). The primary outcome was good neurologic recovery at the time of discharge from the hospital. Multivariate logistic regression analysis was performed, adjusting for patient-community and prehospital variables. Among 54,436 patients, 29,995 patients (55.1%), 21,552 patients (39.6%), and 2889 patients (5.3%) were treated by single-tiered EMS, early multi-tiered EMS, and late multi-tiered EMS, respectively. Good neurological recovery and survival to discharge were more frequent in the early multi-tiered response group (6.4% and 9.7%) than in the single-tiered response group (4.8% and 7.5%) or late multi-tiered response group (3.1% and 5.8%). Compared to the single-tiered response group, the early multi-tiered response group was more likely to have good neurological recovery (adjusted OR, 95% CI: 1.15 [1.06-1.26]), but the late multi-tiered response group was less likely to have good neurological recovery (adjusted OR, 95% CI: 0.76 [0.61-0.96]). In our basic to intermediate-tiered EMS system, early multi-tier response was associated with improved survival and good neurological recovery.

Out-of-hospital cardiac arrest (OHCA) Survey in Lombardy: data analysis through prospective short time period assessment.

Background and aim of the work: The results of out-of-hospital cardiac arrests (OHCA) are usually reported through data collected collected via “ad hoc” registries, but in large populations, samples of short time periods can be used to apply the results to the entire population. We would like to describe the situation of Lombardy to provide evidence on successful procedures, which may be carried out in a larger context. Methods: Observational, prospective, analytical, single cohort study in Lombardy population. Data of OHCA of cardiac aetiology, according to “Utstein Style”, with resuscitation attempts started by the Emergency Medical Service (EMS), were collected for 40 days subdivided in 10-day-periods in all seasons 2014-15 via Operating System “Emergency Management” (EmMa). Results: Of 1219 cases, 536 events of witnessed OHCA of presumed cardiac etiology were analyzed. Outcomes were: sustained Return Of Spontaneous Circulation ROSC (25.6%), Survival Event in Emergency Department (22.8%), Survival after 24 hours (21.2%) and Survival after hospital discharge at home 30 days after (11.2%). Statistically significant results were found in age, rhythm of presentation, and resuscitation by bystanders. Sex, seasonality and rescue timing did not differ statistically. Conclusions: Overall the thirty-day survival rate was similar to studies with larger databases. Our data are consistent with the concept that all emergency service should provide CPR instructions for every citizen who activate the EMS in the suspect of a SCA; further investigation should clarify how long interval could be useful for ROSC and sustained ROSC in patients resuscitated by lay people using CPR instructions. (www.actabiomedica.it)

Ethnic Differences in Direct Transport to PCI-Capable Hospitals Following OHCA

Background: Ethnic disparities exist in survival from out-of-hospital cardiac arrest (OHCA) in New Zealand. This study investigates how receiving-hospital impacts on outcomes, comparing hospitals with, or without, percutaneous coronary intervention (PCI) capability. Method: A retrospective observational study using St John New Zealand OHCA registry data for adult patients treated for OHCA of presumed cardiac aetiology between 1 October 2013 and 31 October 2018. Demographic characteristics were investigated using Chi-Squared analysis. Binary logistic regression modelling was used to investigate outcome differences in survival at thirty-days post-event, according to receiving-hospital PCI-capability. Results: Following an OHCA, 1750 patients were transported to hospital with sustained return-of-spontaneous-circulation (ROSC). Pacific Peoples (86.2%) had the highest proportion of transport to PCI-capable hospitals, followed by European (55.6%) then Māori (32.9%) (p < 0.001). Overall, a lower proportion of patients >65 years (49.9%) were conveyed to PCI-capable hospitals compared to younger age groups, 15–44 years (52.1%) and 45–64 years (59.7%) (p < 0.001). A lower proportion of patients located rurally (34.7%) were transported to PCI-capable hospitals compared to patients in urban locations (59.1%) (p < 0.001). Thirty-day survival was higher in patients transported to hospitals with PCI-capability (Adjusted OR 1.285, 95%CI (1.01 to 1.63), p = 0.04). Median ambulance transport time from OHCA scene to PCI-capable hospitals (13 minutes) was longer compared to non-PCI-capable hospitals (10 minutes) (p < 0.001). Conclusions: Inequities in healthcare may exist related to ethnicity, age, and rurality, associated with receiving-hospital capability. These warrant further investigation. Survival was significantly increased in patients conveyed to hospitals with PCI-capability compared to those who were not.

Neurological prognostication tools in out-of-hospital cardiac arrest patients in Danish intensive care units from 2005 to 2013.

Neurological prognostication is an essential part of post-resuscitation care in out-of-hospital cardiac arrest (OHCA). This study aims to assess the use of computed tomography (CT) and magnetic resonance imaging (MR) of the head, electroencephalography (EEG), and somatosensory evoked potentials (SSEP) in neurological prognostication in resuscitated OHCA patients and factors associated with their use in Danish tertiary and non-tertiary centers from 2005 to 2013 and associations with outcome. We used the Danish Cardiac Arrest Registry to identify patients ≥18years of age admitted to intensive care units due to OHCA of presumed cardiac etiology. CT 0-20days and MR, SSEP, and EEG ≥2-20days post OHCA were considered related to prognostication. Incidence and factors associated with procedures were assessed by multiple Cox regression with death as competing risk. Use of CT, MR, EEG, and SSEP increased during the study period (CT: 51%-67%, HRCT : 1.06, CI: 1.03-1.08, MR: 2%-5%, P=.08, EEG: 6%-33%, HREEG : 1.25, CI: 1.19-1.30, SSEP: 4%-15%, HRSSEP : 1.23, CI: 1.15-1.32). EEG and SSEP were more used in tertiary centers than non-tertiary (HREEG : 1.86, CI: 1.51-2.29, HRSSEP : 4.44, CI: 2.86-6.89). Use of CT, SSEP, and EEG were associated with higher 30-day mortality, and MR was associated with lower (HRCT : 1.15, CI: 1.01-1.30, HRMR : 0.53, CI: 0.37-0.77, HRSSEP : 1.90, CI: 1.57-2.32, HREEG : 1.75, CI: 1.49-2.05). Use of neurological prognostication procedures increased during the study period. EEG and SSEP were more used in tertiary centers. CT, EEG and SSEP were associated with increased mortality.

Analysis of bystander CPR quality during out-of-hospital cardiac arrest using data derived from automated external defibrillators

BackgroundLittle is known regarding the quality of cardiopulmonary resuscitation (CPR) performed by bystanders in out-of-hospital cardiac arrest (OHCA). We sought to determine quality of bystander CPR provided during OHCA using CPR quality data stored by Automated External Defibrillators (AEDs). MethodsWe used the Resuscitation Outcomes Consortium database to identify OHCA cases of presumed cardiac etiology where an AED was utilized. We then matched AED data to each case identified. AED data was analyzed using manufacturer software in order to determine overall measures of bystander CPR quality, changes in bystander CPR quality over time, and adherence to existing 2010 Resuscitation Quality Guidelines. Results100 cases of OHCA of presumed cardiac etiology involving bystander CPR and with corresponding AED data. Mean age was 62.3 years, and 75% were male. Bystanders demonstrated high-quality CPR over all minutes of resuscitation, with a chest compression fraction of 76%, a compression depth of 5.3 cm, and a compression rate of 111.2 compressions/min. Mean perishock pause was 26.8 s. Adherence rates to 2010 Resuscitation Guidelines for compression rate and depth were found to be 66% and 55%, respectively. CPR quality was lowest in the first minute, resulting from increased delay to rhythm analysis (mean 40.7 s). In cases involving shock delivery, latency from initiation of AED to shock delivery was 59.2 s. ConclusionsWe found that bystanders perform high-quality CPR, with strong adherence rates to existing Resuscitation Guidelines. High-quality CPR is maintained over the first five minutes of resuscitation, but was lowest in the first minute.