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

Target Temperature Management Effect on the Clinical Outcome of Patients with Out-of-Hospital Cardiac Arrest Treated with Extracorporeal Cardiopulmonary Resuscitation: A Nationwide Observational Study.

This study aimed to investigate whether targeted temperature management (TTM) could enhance outcomes in patients with out-of-hospital cardiac arrest (OHCA) treated with extracorporeal cardiopulmonary resuscitation (ECPR) for refractory cardiac arrest. Using a nationwide OHCA registry, adult patients with witnessed OHCA of presumed cardiac origin who underwent ECPR at the emergency department between 2008 and 2021 were included. We examined the effect of ECPR with TTM on survival and neurological outcomes at hospital discharge using propensity score matching and multivariable logistic regression compared with patients treated with ECPR without TTM. Odds ratios and 95% confidence intervals were determined. A total of 399 ECPR cases were analyzed among 380,239 patients with OHCA. Of these, 330 underwent ECPR without TTM and 69 with TTM. After propensity score matching, 69 matched pairs of patients were included in the analysis. No significant differences in survival and good neurological outcomes between the two groups were observed. In the multivariable logistic regression, no significant differences were observed in survival and neurological outcomes between ECPR with and without TTM. Among the patients who underwent ECPR after OHCA, ECPR with TTM did not improve outcomes compared with ECPR without TTM.

Extracorporeal cardiopulmonary resuscitation-based approach to refractory out-of-hospital cardiac arrest: A focus on organ donation, a secondary analysis of a Prague OHCA randomized study

BackgroundRefractory out-of-hospital cardiac arrest (OHCA) has a poor outcome. In patients, who cannot be rescued despite using advanced techniques like extracorporeal cardiopulmonary resuscitation (ECPR), organ donation may be considered. This study aims to evaluate, in refractory OHCA, how ECPR versus a standard-based approach allows organ donorship. MethodsThe Prague OHCA trial randomized adults with a witnessed refractory OHCA of presumed cardiac origin to either an ECPR-based or standard approach. Patients who died of brain death or those who died of primary circulatory reasons and were not candidates for cardiac transplantation or durable ventricle assist device were evaluated as potential organ donors by a transplant center. In this post-hoc analysis, the effect on organ donation rates and one-year organ survival in recipients was examined. ResultsOut of 256 enrolled patients, 75 (29%) died prehospitally or within 1 hour after admission and 107 (42%) during the hospital stay. From a total of 24 considered donors, 21 and 3 (p = 0.01) were recruited from the ECPR vs standard approach arm, respectively. Fifteen brain-dead and none cardiac-dead subjects were ultimately accepted, 13 from the ECPR and two from the standard strategy group. A total of 36 organs were harvested. The organs were successfully transplanted into 34 recipients. All transplanted organs were fully functional, and none of the recipients died due to graft failure within the one-year period post-transplant. ConclusionThe ECPR-based approach in the refractory OHCA trial is associated with increased organ donorship and an excellent outcome of transplanted organs.Trial registration: ClinicalTrials.gov Identifier: NCT 01511666. Registered January 19, 2012.

Coronary Angiography After Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation

Myocardial infarction is a frequent cause of out-of-hospital cardiac arrest (OHCA). The long-term effect of early coronary angiography on patients with OHCA with possible coronary trigger but no ST-segment elevation remains unclear. To compare the clinical outcomes of early unselective angiography with the clinical outcomes of a delayed or selective approach for successfully resuscitated patients with OHCA of presumed cardiac origin without ST-segment elevation at 1-year follow-up. The TOMAHAWK trial was a multicenter, international (Germany and Denmark), investigator-initiated, open-label, randomized clinical trial enrolling 554 patients between November 23, 2016, to September 20, 2019. Patients with stable return of spontaneous circulation after OHCA of presumed cardiac origin but without ST-segment elevation on the postresuscitation electrocardiogram were eligible for inclusion. A total of 554 patients were randomized to either immediate coronary angiography after hospital admission or an initial intensive care assessment with delayed or selective angiography after a minimum of 24 hours. All 554 patients were included in survival analyses during the follow-up period of 1 year. Secondary clinical outcomes were assessed only for participants alive at 1 year to account for the competing risk of death. Early vs delayed or selective coronary angiography and revascularization if indicated. Evaluations in this secondary analysis included all-cause mortality after 1 year, as well as severe neurologic deficit, myocardial infarction, and rehospitalization for congestive heart failure in survivors at 1 year. A total of 281 patients were randomized to the immediate angiography group and 273 to the delayed or selective group, with a median age of 70 years (IQR, 60-78 years). A total of 369 of 530 patients (69.6%) were male, and 268 of 483 patients (55.5%) had a shockable arrest rhythm. At 1 year, all-cause mortality was 60.8% (161 of 265) in the immediate angiography group and 54.3% (144 of 265) in the delayed or selective angiography group without significant difference between the treatment strategies, trending toward an increase in mortality with immediate angiography (hazard ratio, 1.25; 95% CI, 0.99-1.57; P = .05). For patients surviving until 1 year, the rates of severe neurologic deficit, myocardial infarction, and rehospitalization for congestive heart failure were similar between the groups. This study found that a strategy of immediate coronary angiography does not provide clinical benefit compared with a delayed or selective invasive approach for patients 1 year after resuscitated OHCA of presumed coronary cause and without ST-segment elevation. ClinicalTrials.gov Identifier: NCT02750462.

Differences in Automated External Defibrillator Types in Out-of-Hospital Cardiac Arrest Treated by Police First Responders

Background: Police first responder systems also including automated external defibrillation (AED) has in the past shown considerable impact on favourable outcomes after out-of-hospital cardiac arrest (OHCA). While short hands-off times in chest compressions are known to be beneficial, various AED models use different algorithms, inducing longer or shorter durations of crucial timeframes along basic life support (BLS). Yet, data on details of these differences, and also of their potential impact on clinical outcomes are scarce. Methods: For this retrospective observational study, patients with OHCA of presumed cardiac origin and initially shockable rhythm treated by police first responders in Vienna, Austria, between 01/2013 and 12/2021 were included. Data from the Viennese Cardiac Arrest Registry and AED files were extracted, and exact timeframes were analyzed. Results: There were no significant differences in the 350 eligible cases in demographics, return of spontaneous circulation, 30-day survival, or favourable neurological outcome between the used AED types. However, the Philips HS1 and -FrX AEDs showed immediate rhythm analysis after electrode placement (0 [0-1] s) and almost no shock loading time (0 [0-1] s), as opposed to the LP CR Plus (3 [0-4] and 6 [6-6] s, respectively) and LP 1000 (3 [2-10] and 6 [5-7] s, respectively). On the other hand, the HS1 and -FrX had longer analysis times of 12 [12-16] and 12 [11-18] s than the LP CR Plus (5 [5-6] s) and LP 1000 (6 [5-8] s). The duration from when the AED was turned on until the first defibrillation were 45 [28-61] s (Philips FrX), 59 [28-81] s (LP 1000), 59 [50-97] s (HS1), and 69 [55-85] s (LP CR Plus). Conclusion: In a retrospective analysis of OHCA-cases treated by police first responders, we could not find significant differences in clinical patient outcomes concerning the respective used AED model. However, various differences in time durations (e.g., electrode placement to rhythm analysis, analysis duration, or AED turned on until first defibrillation) along the BLS algorithm were seen. This opens up the question of AED-adaptations and tailored training methods for professional first responders.

Abstract 267: Differences Of Temporal Trends In Outcomes After Out-of-hospital Cardiac Arrest Between Urban And Rural Regions In Japan: A 4-year Observational Study From 2016 To 2019

Introduction: Recently, multiple studies have demonstrated improvement in survival after out-of-hospital cardiac arrest (OHCA). However, outcomes after OHCA vary with region and city worldwide. Hypothesis: Differences of temporal trends in outcomes after OHCA between rural and urban regions in Japan were postulated. Methods: We included 98,496 patients (aged ≥18 years) using an All-Japan Utstein-style Registry who were witnessed by bystanders after OHCA of presumed cardiac origin between January 1, 2016 and December 31, 2019. Based on population density, patients were classified into urban (n=76,411, 28 prefectures with a population of ≥200 inhabitants/km 2 ) and rural (n=22,085, 19 prefectures with a population of <200 inhabitants/km 2 ) groups. The study endpoints were 1-month survival and neurologically intact survival, defined with a cerebral performance category (CPC) score of 1 or 2. Results: The mean age in rural regions significantly increased from 77.1 years to 77.8 years ( P <0.01) despite unchanged patients’ age in urban regions for 4 years ( P =0.45). The bystander cardiopulmonary resuscitation (B-CPR) rate in urban regions significantly increased from 54.0% to 55.7% ( P <0.01) unlike in rural regions ( P =0.45). The overall crude 1-month survival and CPC 1-2 rates during the study periods were 10.9% and 6.8%, respectively. The overall 1-month survival and CPC 1-2 rates significantly improved from 2016 to 2019; the corresponding risk-adjusted ratios per year were 1.04 [95% confidence interval (CI), 1.02-1.07, P <0.01] and 1.03 [1.01-1.06, P <0.05]. In the urban group, 1-month survival and CPC 1-2 rates significantly improved from 2016 to 2019; the corresponding risk-adjusted ratios per year were 1.05 [95% CI, 1.03-1.08, P <0.01] and 1.04 [1.01-1.07, P <0.01]. However, in the rural group, 1-month outcomes did not significantly improve from 2016 to 2019; the corresponding risk-adjusted ratios per year were 0.99 [95% CI, 0.95-1.04, P =0.68] and 1.01 [0.95-1.07, P =0.74]. Conclusions: One-month outcomes after OHCA significantly improved over the recent 4 years in urban regions, unlike in rural regions in Japan. No change in B-CPR rate in rural regions was noted, and an increase in the B-CPR rate in urban regions may be associated with these results.

Abstract 274: Identifying Target Populations For Extracorporeal Cardiopulmonary Resuscitation Among Patients With Refractory Out-of-hospital Cardiac Arrest Using Machine Learning

Introduction: Extracorporeal cardiopulmonary resuscitation (ECPR) can be used on patients with out-of-hospital cardiac arrest (OHCA) when the cause is potentially reversible. However, little is known about the optimal target populations for ECPR among those with refractory OHCA. Methods: We retrospectively analyzed nationwide OHCA registry data on 57,754 patients from 93 hospitals in Japan, 2014-2019. We identified 1,273 patients having a witness or initially shockable rhythms with refractory OHCA of presumed cardiac origin without return of spontaneous circulation after >3 doses of adrenaline administration and defibrillations when necessary at the emergency department (ED). We used the causal forest—a machine learning method to estimate heterogeneous treatment effects—to determine individual treatment effects of ECPR on a favorable 30-day neurologic outcome defined as the Cerebral Performance Category scale of 1 or 2, adjusting for confounders (e.g., age, sex, initial cardiac rhythms, and laboratory data). We compared patient characteristics in each quintile of individual ECPR effects to identify potential determinants of ECPR effects in patients with refractory OHCA. Finally, to determine optimal targets of ECPR, we evaluated how ECPR effects could vary depending on patient characteristics. Results: We found that the treatment effects of ECPR on a favorable neurologic outcome were heterogeneous (top 20% vs. others, 0.15 vs. 0.00; p<0.001) ( Figure 1 ). The key determinants of ECPR effects were initial cardiac rhythms on the emergency medical service (EMS) and at ED arrival, regardless of EMS transport time or laboratory data. In addition, ECPR effects varied depending on the information on ED arrival (i.e., witness, bystander CPR, and initial cardiac rhythms) ( Figure 2 ). Conclusion: Among patients with refractory OHCA, information available on arrival at the ED could effectively identify patients who may particularly benefit from ECPR.

Extracorporeal versus conventional cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest: a secondary analysis of the Prague OHCA trial

BackgroundSurvival rates in refractory out-of-hospital cardiac arrest (OHCA) remain low with conventional advanced cardiac life support (ACLS). Extracorporeal life support (ECLS) implantation during ongoing resuscitation, a method called extracorporeal cardiopulmonary resuscitation (ECPR), may increase survival. This study examined whether ECPR is associated with improved outcomes.MethodsPrague OHCA trial enrolled adults with a witnessed refractory OHCA of presumed cardiac origin. In this secondary analysis, the effect of ECPR on 180-day survival using Kaplan–Meier estimates and Cox proportional hazard model was examined.ResultsAmong 256 patients (median age 58 years, 83% male) with median duration of resuscitation 52.5 min (36.5–68), 83 (32%) patients achieved prehospital ROSC during ongoing conventional ACLS prehospitally, 81 (32%) patients did not achieve prehospital ROSC with prolonged conventional ACLS, and 92 (36%) patients did not achieve prehospital ROSC and received ECPR. The overall 180-day survival was 51/83 (61.5%) in patients with prehospital ROSC, 1/81 (1.2%) in patients without prehospital ROSC treated with conventional ACLS and 22/92 (23.9%) in patients without prehospital ROSC treated with ECPR (log-rank p < 0.001). After adjustment for covariates (age, sex, initial rhythm, prehospital ROSC status, time of emergency medical service arrival, resuscitation time, place of cardiac arrest, percutaneous coronary intervention status), ECPR was associated with a lower risk of 180-day death (HR 0.21, 95% CI 0.14–0.31; P < 0.001).ConclusionsIn this secondary analysis of the randomized refractory OHCA trial, ECPR was associated with improved 180-day survival in patients without prehospital ROSC.Trial registration: ClinicalTrials.gov Identifier: NCT01511666, Registered 19 January 2012.

Effect of Intra-arrest Transport, Extracorporeal Cardiopulmonary Resuscitation, and Immediate Invasive Assessment and Treatment on Functional Neurologic Outcome in Refractory Out-of-Hospital Cardiac Arrest

<h3>Importance</h3> Out-of-hospital cardiac arrest (OHCA) has poor outcome. Whether intra-arrest transport, extracorporeal cardiopulmonary resuscitation (ECPR), and immediate invasive assessment and treatment (invasive strategy) is beneficial in this setting remains uncertain. <h3>Objective</h3> To determine whether an early invasive approach in adults with refractory OHCA improves neurologically favorable survival. <h3>Design, Setting, and Participants</h3> Single-center, randomized clinical trial in Prague, Czech Republic, of adults with a witnessed OHCA of presumed cardiac origin without return of spontaneous circulation. A total of 256 participants, of a planned sample size of 285, were enrolled between March 2013 and October 2020. Patients were observed until death or day 180 (last patient follow-up ended on March 30, 2021). <h3>Interventions</h3> In the invasive strategy group (n = 124), mechanical compression was initiated, followed by intra-arrest transport to a cardiac center for ECPR and immediate invasive assessment and treatment. Regular advanced cardiac life support was continued on-site in the standard strategy group (n = 132). <h3>Main Outcomes and Measures</h3> The primary outcome was survival with a good neurologic outcome (defined as Cerebral Performance Category [CPC] 1-2) at 180 days after randomization. Secondary outcomes included neurologic recovery at 30 days (defined as CPC 1-2 at any time within the first 30 days) and cardiac recovery at 30 days (defined as no need for pharmacological or mechanical cardiac support for at least 24 hours). <h3>Results</h3> The trial was stopped at the recommendation of the data and safety monitoring board when prespecified criteria for futility were met. Among 256 patients (median age, 58 years; 44 [17%] women), 256 (100%) completed the trial. In the main analysis, 39 patients (31.5%) in the invasive strategy group and 29 (22.0%) in the standard strategy group survived to 180 days with good neurologic outcome (odds ratio [OR], 1.63 [95% CI, 0.93 to 2.85]; difference, 9.5% [95% CI, −1.3% to 20.1%];<i>P</i> = .09). At 30 days, neurologic recovery had occurred in 38 patients (30.6%) in the invasive strategy group and in 24 (18.2%) in the standard strategy group (OR, 1.99 [95% CI, 1.11 to 3.57]; difference, 12.4% [95% CI, 1.9% to 22.7%];<i>P</i> = .02), and cardiac recovery had occurred in 54 (43.5%) and 45 (34.1%) patients, respectively (OR, 1.49 [95% CI, 0.91 to 2.47]; difference, 9.4% [95% CI, −2.5% to 21%];<i>P</i> = .12). Bleeding occurred more frequently in the invasive strategy vs standard strategy group (31% vs 15%, respectively). <h3>Conclusions and Relevance</h3> Among patients with refractory out-of-hospital cardiac arrest, the bundle of early intra-arrest transport, ECPR, and invasive assessment and treatment did not significantly improve survival with neurologically favorable outcome at 180 days compared with standard resuscitation. However, the trial was possibly underpowered to detect a clinically relevant difference. <h3>Trial Registration</h3> ClinicalTrials.gov Identifier:NCT01511666

Multi-centre implementation of an Educational program to improve the Cardiac Arrest diagnostic accuracy of ambulance Telecommunicators and survival outcomes for sudden cardiac arrest victims: the EduCATe study design and methodology

BackgroundSudden cardiac death remains a leading cause of mortality in Canada, resulting in more than 35,000 deaths annually. Most cardiac arrest victims collapse in their own home (85% of the time) and 50% are witnessed by a family member or bystander. Survivors have a quality of life similar to the general population, but the overall survival rate for out-of-hospital cardiac arrest (OHCA) rarely exceeds 8%. Victims are almost four times more likely to survive when receiving bystander CPR, but bystander CPR rates have remained low in Canada over the past decade, not exceeding 15–25% until recently. Telecommunication-assisted CPR instructions have been shown to significantly increase bystander CPR rates, but agonal breathing may be misinterpreted as a sign of life by 9–1-1 callers and telecommunicators, and is responsible for as much as 50% of missed OHCA diagnoses.We sought to improve the ability and speed with which ambulance telecommunicators can recognize OHCA over the phone, initiate timely CPR instructions, and improve survival.MethodsIn this multi-center national study, we will implement and evaluate an educational program developed for ambulance telecommunicators using a multiple baseline interrupted time-series design. We will compare outcomes 12 months before and after the implementation of a 20-min theory-based educational video addressing barriers to recognition of OHCA while in the presence of agonal breathing. Participating Canadian sites demonstrated prior ability to collect standardized data on OHCA. Data will be collected from eligible 9–1-1 recordings, paramedic documentation and hospital medical records. Eligible cases will include suspected or confirmed OHCA of presumed cardiac origin in patients of any age with attempted resuscitation.DiscussionThe ability of telecommunication-assisted CPR instructions to improve bystander CPR and survival rates for OHCA victims is undeniable. The ability of telecommunicators to recognize OHCA over the phone is unequivocally impeded by relative lack of training on agonal breathing, and reluctance to initiate CPR instructions when in doubt. Our pilot data suggests the potential impact of this project will be to increase absolute OHCA recognition and bystander CPR rates by at least 10%, and absolute out-of-hospital cardiac arrest survival by 5% or more.Trial registrationProspectively registered on March 28, 2019 at ClinicalTrials.gov identifier: NCT03894059.

Gender-specific differences in return-to-spontaneous circulation and outcome after out-of-hospital cardiac arrest: Results of sixteen-year-state-wide initiatives

AimSeveral studies reported a lower proportion of laypeople cardio-pulmonary resuscitation (CPR) in female victims of out-of-hospital cardiac arrest (OHCA). We aimed to verify how sixteen-years of state-wide initiatives impacted on gender-differences in OHCA treatment and survival. MethodsAll the 2481 consecutive OHCAs of presumed cardiac origin occurred between 2002 and 2018 in the Swiss Ticino Canton and in which a resuscitation was attempted, were included. Emergency medical system (EMS)-witnessed OHCAs were excluded. ResultsTime from call to CPR decreased from 9-min in 2002–2006 to 5-min in 2015–2018 (p<0.01) and until 2014, it was longer in women. Survival to discharge increased overall from 11% in 2002–2006 to 23% in 2015–2018 (p<0.001) related to telephone-assisted CPR development (period 2011–2014) and first responder and layperson recruitment via a mobile application (period 2015–2018). In males, survival increased from 12% to 25% (p=0.001) with a statistically significant increase in odds of survival in 2007–2010 (OR 1.6 95%CI 1.1–2.3; p=0.001), in 2011–2014 (OR 2 95%CI 1.4–2.8; p=0.001), and in 2015–2018 (2.4 95%CI 1.7–3.3; p=0.001) compared to 2002–2006. On the other hand, in females, survival increased from 7% to 18% (p<0.001), with a corresponding increase in the odds of survival of almost 3 times from 2002–2006 to 2015–2018 time period (OR 2.9 95%CI 1.5–5.8, p=0.001). No difference in survival probability was observed according to gender when adjusted for age, presenting rhythm, year-groups, OHCA location, EMS arrival time, witnessed status and laypeople-CPR. ConclusionsState-wide initiatives can significantly increase the chances of survival in both male and female victims of OHCAs, by increasing the probability to receive CPR in a shorter time span.

Spatio-temporal prediction model of out-of-hospital cardiac arrest: Designation of medical priorities and estimation of human resources requirement.

To determine the out-of-hospital cardiac arrest (OHCA) rates and occurrences at municipality level through a novel statistical model accounting for temporal and spatial heterogeneity, space-time interactions and demographic features. We also aimed to predict OHCAs rates and number at municipality level for the upcoming years estimating the related resources requirement. All the consecutive OHCAs of presumed cardiac origin occurred from 2005 until 2018 in Canton Ticino region were included. We implemented an Integrated Nested Laplace Approximation statistical method for estimation and prediction of municipality OHCA rates, number of events and related uncertainties, using age and sex municipality compositions. Comparisons between predicted and real OHCA maps validated our model, whilst comparisons between estimated OHCA rates in different yeas and municipalities identified significantly different OHCA rates over space and time. Longer-time predicted OHCA maps provided Bayesian predictions of OHCA coverages in varying stressful conditions. 2344 OHCAs were analyzed. OHCA incidence either progressively reduced or continuously increased over time in 6.8% of municipalities despite an overall stable spatio-temporal distribution of OHCAs. The predicted number of OHCAs accounts for 89% (2017) and 90% (2018) of the yearly variability of observed OHCAs with prediction error ≤1OHCA for each year in most municipalities. An increase in OHCAs number with a decline in the Automatic External Defibrillator availability per OHCA at region was estimated. Our method enables prediction of OHCA risk at municipality level with high accuracy, providing a novel approach to estimate resource allocation and anticipate gaps in demand in upcoming years.

Variability in the effects of prehospital advanced airway management on outcomes of patients with out-of-hospital cardiac arrest.

ObjectiveTo investigate variations in the effects of prehospital advanced airway management (AAM) on outcomes of out-of-hospital cardiac arrest (OHCA) patients according to regional emergency medical service (EMS) systems in four Asian cities.MethodsWe enrolled adult patients with EMS-treated OHCA of presumed cardiac origin between 2012 and 2014 from Osaka (Japan), Seoul (Republic of Korea), Singapore (Singapore), and Taipei (Taiwan). The main exposure variable was prehospital AAM. The primary endpoint was neurological recovery. We compared outcomes between the prehospital AAM and non-AAM groups using multivariable logistic regression with an interaction term between prehospital AAM and the four Asian cities.ResultsA total of 16,510 patients were included in the final analyses. The rates of prehospital AAM varied among Osaka, Seoul, Singapore, and Taipei (65.0%, 19.2%, 84.9%, and 34.1%, respectively). The non-AAM group showed better outcomes than the AAM group (adjusted odds ratio [aOR] for neurological recovery 0.30; 95% confidence interval [CI], 0.24–0.38]). In the interaction model for neurological recovery, the aORs for AAM in Osaka and Singapore were 0.12 (95% CI, 0.06–0.26) and 0.21 (95% CI, 0.16–0.28), respectively. In Seoul and Taipei, the association between prehospital AAM and neurological recovery was not significant (aOR 0.58 [95% CI, 0.31–1.10] and 0.79 [95% CI, 0.52–1.20], respectively). The interaction between prehospital AAM and region was significant (P=0.01).ConclusionThe effects of prehospital AAM on outcomes of OHCA patients differed according to regional variability in the EMS systems.

Intravenous versus intraosseous adrenaline administration in out-of-hospital cardiac arrest: A retrospective cohort study

BackgroundAdrenaline is an important component in the resuscitation of individuals experiencing out-of-hospital cardiac arrest (OHCA). The 2018 Advanced Cardiac Life Support (ACLS) algorithm gives the option of either intravenous (IV) or intraosseous (IO) routes for adrenaline administration during cardiac arrest. However, the optimal route during prehospital resuscitation remains controversial. This study aims to investigate whether IV and IO routes lead to different outcomes in OHCA patients who received prehospital adrenaline. MethodsThis retrospective analysis included adult patients with OHCA of presumed cardiac origin who had Emergency Medical Services (EMS) CPR, received adrenaline, and were enrolled in the Resuscitation Outcomes Consortium (ROC) Cardiac Epistry version 3 database between 2011 and 2015. We divided the study population into IV and IO groups based on the administration route. Logistic regression analysis was performed to evaluate the association between adrenaline delivery routes and prehospital return of spontaneous circulation (ROSC), survival to hospital discharge, and favorable neurological outcome. ResultsOf the 35,733 patients included, 27,758 (77.7%) had adrenaline administered via IV access and 7975 (22.3%) via IO access. With the IO group as a reference in the logistic regression model, the adjusted odds ratios of the IV group for prehospital ROSC, survival and favorable neurological outcome were 1.367 (95%CI, 1.276–1.464), 1.468 (95%CI, 1.264–1.705) and 1.849 (95%CI, 1.526–2.240), respectively. Similar results were found in the propensity score matched population and subgroup analysis. ConclusionCompared with the IO approach, the IV approach appears to be the optimal route for adrenaline administration in advanced life support for OHCA during prehospital resuscitation.

Impact of age on survival of patients with out-of-hospital cardiac arrest transported to tertiary emergency medical institutions in Osaka, Japan.

The purpose of this study was to evaluate the out-of-hospital cardiac arrest (OHCA) characteristics of patients stratified by age who had resuscitation attempted and were transported to tertiary emergency medical institutions in Osaka Prefecture, Japan; especially those of advanced age. A prospective, population-based, observational review was carried out of consecutive OHCA patients with emergency responder resuscitation attempts from July 2012 to December 2016 in Osaka, Japan. Patients were classified into four groups: (i) 18-64 years; (ii) 65-74 years; (iii) 75-84 years; and (iv) ≥85 years. Patient, event and treatment characteristics were examined for patients with presumed cardiac etiology of OHCA. The primary outcome was the 1-month survival with a neurologically favorable outcome. A total of 4636 patients with OHCA of presumed cardiac origin were transported to tertiary emergency medical institutions. The number of patients in the four groups was as follows: (i) 1290 (27.8%); (ii) 1102 (23.8%); (iii) 1420 (30.6%); and (iv) 824 (17.8%). The 1-month survival with a neurologically favorable outcome was: (i) 207 (16.0%); (ii) 96 (8.7%); (iii) 60 (4.2%); and (iv) seven (0.85%). In a multivariate analysis for 1-month survival with a neurologically favorable outcome, increased age was a significant prognostic factor (≥85 years; adjusted odds ratio 0.08, 95% confidence interval 0.03-0.23) for poor outcomes. In this population, advanced age (≥85 years) was strongly associated with poor outcomes. Further discussion of policies directed at resuscitation of very elderly OHCA patients is required, considering limited medical resources and the rapidly aging population in Japan. Geriatr Gerontol Int 2019; 19: 1088-1095.

P2671The addition of admission lactate to the CREST risk score to determine prognosis in out of hospital cardiac arrest: the C-AREST score

Abstract Introduction There has been an increasing focus on the development of scoring systems for patients admitted following resuscitation from out-of-hospital cardiac arrest (OHCA) to determine both prognosis and short-term management. One such system, the CREST score, has been shown to predict circulatory aetiology death in patients without ST-elevation myocardial infarction, however with an increasing number of OHCAs seen, general scoring systems to predict outcome in OHCA would be helpful. Aims We sought to determine whether the addition of an admission lactate ≥8 mmol/l to the existing CREST score was able to better predict in-hospital mortality in patients admitted with OHCA. Methods and results We retrospectively analysed the data of 500 patients admitted with an OHCA of presumed cardiac origin to our tertiary cardiac centre between June 2014 and Oct 2018. Mean age was 62.6y (±14.7), 379 (76%) were male and 250 (50%) were Caucasian. 313 (62.6%) were admitted with ST elevation myocardial infarction or equivalent. 48.6% (243/500) of patients died in hospital and of those that survived, 20.2% (52/257) were left with hypoxic brain injury (CPC score 3–4). When analysed independently, all individual factors other than history of Coronary artery disease (OR 1.47, p=0.084) significantly predicted in-hospital mortality: Admission lactate ≥8 mmol/l (OR 6.78, p&lt;0.0001), non-shockable Rhythm (OR 10.9, p&lt;0.0001), Ejection fraction &lt;30% (OR 5.84, p&lt;0.0001), Shock at presentation (OR 5.49, p&lt;0.0001) and ischaemic Time &gt;25 minutes (OR 12.8, p&lt;0.0001). When each factor was assigned one point and totalled, both increasing CREST and C-AREST scores were associated with increasing in-hospital mortality: CREST (0–5 points): 4.3%, 30.5%, 41.5%, 85.6%, 95.2%, 100% vs C-AREST (0–6 points): 9.1%, 28.3%, 41.9%, 62.8%, 97.6%, 96.4%, 100%. When analysed with stepwise logistic regression, the addition of admission lactate ≥8 mmol/l to the model improved the prediction of in-hospital mortality: CREST (40.8% of variance explained) vs C-AREST (43.3%), with admission lactate remaining an independently significant predictor (OR 3.67, p=0.002). Conclusion We describe a novel modification to the previously described CREST scoring system for OHCA: the C-AREST score. The addition of admission lactate ≥8 mmol/l may have a role in differentiating those in intermediate risk categories (score between 2 and 3) where the predicted in hospital mortality would otherwise vary greatly. Given the relative ease of obtaining admission lactate, this scoring system may further improve stratification of patients who may or may not benefit from invasive management.

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...

Future projections of temperature-related excess out-of-hospital cardiac arrest under climate change scenarios in Japan

BackgroundRecent studies have reported associations between global climate change and mortality. However, future projections of temperature-related out-of-hospital cardiac arrest (OHCA) have not been thoroughly evaluated. Thus, we aimed to project temperature-related morbidity for OHCA concomitant with climate change. MethodsWe collected national registry data on all OHCA cases reported in 2005–2015 from all 47 Japanese prefectures. We used a two-stage time series analysis to estimate temperature-OHCA relationships. Time series of current and future daily mean temperature variations were constructed according to four climate change scenarios of representative concentration pathways (RCPs) using five general circulation models. We projected excess morbidity for heat and cold and the net change in 1990–2099 for each climate change scenario using the assumption of no adaptation or population changes. ResultsDuring the study period, 739,717 OHCAs of presumed cardiac origin were reported. Net decreases in temperature-related excess morbidity were observed under higher emission scenarios. The net change in 2090–2099 compared with 2010–2019 was −0.8% (95% empirical confidence interval [eCI]: −1.9, 0.1) for a mild emission scenario (RCP2.6), −2.6% (95% eCI: −4.4, −0.8) for a stabilization scenario (RCP4.5), −3.4% (95% eCI: −5.7, −1.0) for a stabilization scenario (RCP6.0), and − 4.2% (95% eCI: −8.3, −0.1) for an extreme emission scenario (RCP8.5). ConclusionsOur study indicates that Japan is projected to experience a substantial net reduction in OHCAs in higher-emission scenarios. The decrease in risk is limited to a specific morbidity cause, and a broader assessment within climate change scenarios should consider other direct and indirect impacts.

P115: Outcomes of out of hospital cardiac arrest in First Nations vs. non-First Nations patients in Saskatoon

Introduction: One in nine (11.7%) people in Saskatchewan identifies as First Nations. In Canada, First Nations people experience a higher burden of cardiovascular disease when compared to the general population, but it is unknown whether they have different outcomes in out of hospital cardiac arrest (OHCA). Methods: We reviewed pre-hospital and inpatient records of patients sustaining an OHCA between January 1st, 2015 and December 31st, 2017. The population consisted of patients aged 18 years or older with OHCA of presumed cardiac origin occurring in the catchment area of Saskatoon's EMS service. Variables of interest included, age, gender, First Nations status (as identified by treaty number), EMS response times, bystander CPR, and shockable rhythm. Outcomes of interest included return of spontaneous circulation (ROSC), survival to hospital admission, and survival to hospital discharge. Results: In all, 372 patients sustained OHCA, of which 27 were identified as First Nations. First Nations patients with OHCA tended to be significantly younger (mean age 46 years vs. 65 years, p &amp;lt; 0.0001) and had shorter EMS response times (median times 5.3 minutes vs. 6.2 minutes, p = 0.01). There were no differences between First Nations and non-First Nations patients in terms of incidence of shockable rhythms (24% vs. 26%, p = 0.80), ROSC (42% vs. 41%, p = 0.87), survival to admission (27% vs 33%, p = 0.53), and survival to hospital discharge (15% vs. 12%, p = 0.54). Conclusion: In Saskatoon, First Nations patients sustaining OHCA appear to have similar survival rates when compared with non-First Nations patients, suggesting similar baseline care. Interestingly, First Nations patients sustaining OHCA were significantly younger than their non-First Nations counterparts. This may reflect a higher burden of cardiovascular disease, suggesting a need improved prevention strategies.

Association between ambulance response time and neurologic outcome in patients with cardiac arrest

PurposeEmergency medical services (EMS) response time is one of prehospital factors associated with survival rate of patients with out-of-hospital cardiac arrest (OHCA). The objective of this study was to determine whether short EMS response time was associated with improved neurologic outcome of patients with OHCA through prospective analysis. MethodsWe performed a prospective observational analysis of collected data from KoCARC registry between October 2015 and December 2016. OHCA patients aged 18 years or older with presumed cardiac etiology by emergency physicians in emergency department were included in this study. ResultsOf 3187 cardiac arrest patients enrolled in the KoCARC registry, 2309 patients were included in the final analysis. Response time threshold was 11.5 min for prehospital return of spontaneous circulation and 7.5 min for survival to discharge and favorable neurologic outcome. Patients in the ≤7.5 min response time group showed increased odds of survival to discharge (OR: 1.54, 95% CI: 1.13–2.10, p = .006) and favorable neurologic recovery (OR: 2.01, 95% CI: 1.36–2.99, p = .001). When response time was decreased by 1 min, all outcomes were improved (survival to discharge, OR: 1.08; 95% CI: 1.04–1.12, p < .001; favorable neurological outcome, OR: 1.14, 95% CI: 1.07–1.21, p < .001). ConclusionWe found that shorter EMS response time could lead to favorable neurologic outcome in patients with OHCA of presumed cardiac origin. EMS response time threshold associated with improved favorable outcome was ≤7.5 min.

Abstract 300: Long-Term Survival, Quality of Life and Health Care Costs in the Survivors of Pre-Hospital Cardiac Arrest

Background: Understanding the prognosis of out-of-hospital cardiac arrest (OHCA) patients is vital to informing resuscitation and advanced care planning decisions. However, short-term outcomes such as survival to hospital discharge do not account for post-arrest quality of life and medical costs. Objective: To investigate the survival time, long-term health-related quality of life, and health care costs of OHCA survivors. Methods: We conducted a prospective cohort study of all adult OHCA survivors of cardiac origin between 1 August 2016 and 31 December 2017 in a tertiary medical center in Taiwan. Chinese version of EuroQol-5D-5L (EQ-5D-5L) was used for measuring health-related quality of life at 1 month, 6 month and 1 year post-discharge. Survival and health care costs data were collected. Descriptive statistics and Wilcoxon Signed-Ranks Test were used for data analysis. Results: During the study period, 30 of 163 (18.4%) OHCA of presumed cardiac origin survived to hospital discharge. The mean age for the survivors was 59 years. Most survivors were male (83.3%), and received bystander cardiopulmonary resuscitation (73.3%) and defibrillation (86.7%) in the prehospital settings. Of 30 survivors, 23 patients were cerebral performance category score (CPC) of 1 or 2 and 7 were CPC of 3 or 4. The median hospital stay and estimated median survival time for CPC 1-2 and CPC 3-4 were 17 days, 8.8 years and 34 days, 0.4 years, respectively. The mean EQ-5D-5L visual analogue scale score and index score (utility) for 13 CPC 1-2 survivors followed at 6 month post discharge were 75.58 ± 13.31 and 0.856 ± 0.125, respectively, and were significantly higher than the scores (65.38 ± 15.47, 0.689 ± 0.114) at 1 month. The median health care costs of the index admission and 6 month post-discharge for CPC 1-2 survivors were NT$ 655,866 and NT$ 46,550, respectively. Conclusion: The survival time and health related quality of life for OHCA survivors with good neurologic outcome is good and improves over time. It pays to save those lives.