Outcomes In Out-of-hospital Cardiac Arrest Patients Research Articles

The impact of smartphone-dispatched CPR-trained volunteers on OHCA outcomes is influenced by patient age

The early initiation of cardiopulmonary resuscitation (CPR) measures by non-professionals before the arrival of Emergency Medical Service (EMS) is known to be crucial for improving outcomes after out-of-hospital cardiac arrest (OHCA). We assessed the impact of deploying CPR-trained volunteers via a smartphone-based alerting system on the outcome of OHCA patients. In a retrospective nonrandomized cohort study, all OHCA cases in the city of Aachen over a six-year period were analysed. We compared patient data, CPR metrics, alerting system data as well as outcome data between the intervention and control groups. From June 2017 to May 2023, 101 out of 852 resuscitations were initiated by volunteers alerted via a smartphone-based alerting system in OHCA events. We found no overall rise in the return of spontaneous circulation (ROSC) rate. An age-dependent subgroup analysis indicated an increased incidence of initially shockable rhythms and an increased ROSC rate for patients younger than 60 years in the intervention group, while implying a lower ROSC rate in patients older than 80 years after mobile responder CPR. Although this study was underpowered to yield statistically significant results, our findings suggest the need for an age-sensitive approach when evaluating the effects of first-responder systems on OHCA cases.

Abstract Su904: The association between base excess on arrival at the hospital and neurological outcome of adult out-hospital cardiac arrest: observational study

Background: The relationship between base-excess (BE) values, which take into account the time interval from cardiac arrest to blood test, and neurological outcome after out-of-hospital cardiac arrest (OHCA) is not well understood. The purpose of this study was to evaluate the association between BE on arrival at the hospital and neurological outcomes in OHCA patients. Methods: The CRITICAL study, a prospective, multicenter observational study in Osaka, Japan, registered consecutive OHCA patients who were transported to 16 participating critical care centers from 2012 to 2021. We included adult patients aged 18 years with witnessed OHCA whose BE values on hospital arrival was available, and divided patients into quartiles based on BE values of initial blood test on arrival at the hospital: Q1 (BE ≤ −21.1 mmol/L), Q2 (−21.1 < BE ≤ −15.7 mmol/L), Q3 (−15.7 < BE ≤ −10.4 mmol/L), and Q4 (BE > −10.4 mmol/L). The primary outcome was one-month survival with favorable neurological outcome, defined as cerebral performance category scale 1 or 2. Results: A total of 23,854 patients were registered, and 6,066 of them were eligible for analyses. Neurologically favorable outcome was the lowest in the Q1 group (3.2% [49/1,528]), followed by the Q2 (4.7% [70/1,493]), Q3 (9.8% [148/1,515]), and Q4 (23.5% [359/1,530]) group. In the multivariable logistic regression analysis, the adjusted odds ratio of Q1 compared with Q4 for one-month favorable neurological outcome was 0.13 (95% CI 0.090–0.18). The proportion of one-month favorable neurological outcome decreased progressively across decreasing quartiles (p for trend < 0.001). In subgroup analysis, there was an interaction between presence of return of spontaneous circulation (ROSC) before blood test and neurological outcome (p for interaction < 0.001). The neurological outcome worsened as the BE values decreased among those who achieved ROSC before the blood test (p for trend < 0.001), but not in those without ROSC (p for trend = 0.078). There was not a significant interaction between BE values without ROSC before blood test and time from witness to blood test (p for interaction = 0.501). Conclusions: We demonstrated that lower BE values at hospital arrival were associated with worse neurological outcome. The BE values may be one of the effective prognostic indications for neurological outcome, especially in OHCA patients with ROSC before hospital arrival.

Abstract 4137065: Efficacy and Safety of Extracorporeal CPR in Out-of-Hospital Cardiac Arrest Survival and Neurological Integrity: a Meta-Analysis of Randomized Controlled Trials

Introduction: Out-of-hospital cardiac arrest (OHCA) remains a significant public health challenge, with conventional cardiopulmonary resuscitation (CPR) often yielding limited success. Extracorporeal CPR (eCPR) has emerged as a potential adjunctive therapy to improve outcomes in OHCA patients. Purpose: To evaluate the efficacy and safety of eCPR compared to conventional CPR in OHCA. Methods: A comprehensive search of Cochrane CENTRAL, PubMed, Ovid Medline, and Web of Science databases was conducted independently until November 10, 2023. Randomized controlled trials (RCTs) comparing eCPR with conventional CPR in OHCA were included. Primary efficacy outcome was defined as survival to hospital discharge, while primary safety outcome was assessed for bleeding events. Summary effect measures of the primary outcomes were obtained by pooling the data with an inverse variance–weighted random-effects model. A sensitivity analysis was performed regarding whether the conclusions reached might differ substantially if a single study was omitted. Statistical analyses were performed with “meta” package in R (version 4.3.2) and Revman 5.4. Results: Four unique RCTs involving 435 patients were included in the analysis. ECCPR was associated with a significantly higher rate of survival at 1 month with good neurological outcome (Risk Ratio [RR] 1.55, 95% Confidence Interval (CI) 1.06 to 2.27, I 2 : 0%) but comparable at survival to hospital discharge (RR 1.10, 95% CI 0.16 to 7.30, I 2 : 47%) compared to conventional CPR. Furthermore, no significant differences were observed between eCPR and conventional CPR groups in survival rates at 3 months (RR 1,33, 95% CI 0.92 to 1.94, I 2 : 64%), survival at 6 months with good neurological outcome (RR 1.39, 95% CI 0.97 to 1.99, I 2 : 0%), and survival at 6 months (RR 2.79, 95% CI 0.33 to 23.28, I 2 : 63%). eCPR demonstrated a statistically significant elevation in bleeding events compared to conventional CPR (RR 4.25, 95% CI 2.37 to 7.64, I 2 : 0%). Sensitivity analysis revealed that none of the studies significantly influenced the pooled risk estimate to any great extent. Conclusion: eCPR shows beneficial results in improving short-term survival and neurological outcomes at 1-month post-OHCA. However, it is associated with an elevated risk of bleeding when compared to conventional CPR. Further investigations are imperative to delineate the specific patient populations that stand to gain the most benefit from ECPR intervention.

Efficacy of Intraosseous Versus Intravenous Drug Administration in Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis.

This meta-analysis compared the efficacy of intraosseous (IO) versus intravenous (IV) drug administration in out-of-hospital cardiac arrest (OHCA). We systematically searched Embase, Web of Science, PubMed, and Cochrane Library through September 20, 2024, for relevant studies. The primary outcome was favorable neurological outcome, with secondary outcomes, including survival to hospital discharge and return of spontaneous circulation (ROSC). Seventeen studies, including randomized controlled trials and observational studies, were included in the final analysis. Pooled results showed that IV access was associated with significantly better outcomes compared to IO access. Patients in the IV group had 1.73 times higher odds of favorable neurological outcomes (RR: 1.73, 95% CI: 1.32-2.27), 1.64 times higher odds of survival to hospital discharge (RR: 1.64, 95% CI: 1.27-2.12), and 1.27 times higher odds of ROSC (RR: 1.27, 95% CI: 1.16-1.40). However, significant heterogeneity was observed across studies for all outcomes. These findings suggest that IV access may be superior to IO access in improving outcomes for OHCA patients. However, the high heterogeneity and conflicting results from individual studies highlight the need for careful interpretation and further research. Factors such as ease of access, speed of establishment, and patient condition should also be considered when choosing between IV and IO routes during resuscitation. This meta-analysis underscores the importance of reassessing current guidelines and conducting more robust primary studies to optimize vascular access strategies in OHCA management.

Assessing variations in care delivered to rural out of hospital cardiac arrest patients in the interfacility transfer setting.

There is significant variation in out-of-hospital cardiac arrest (OHCA) outcomes between different regions. We sought to evaluate outcomes of OHCA patients in the interfacility transfer (IFT) setting, between critical care transport (LifeFlight) and community Emergency Medical Services (EMS), in the state of Maine. This was a retrospective analysis of our institution's electronic medical record and the Maine EMS database. Data were collected from January 1, 2019, to December 31, 2021. Only adult OHCA encounters requiring an IFT for definitive post-cardiac-arrest care were included. Demographics, EMS agency, IFT vital signs, targeted temperature management (TTM) medications, cerebral performance category (CPC) scores, survival to discharge, and other descriptive variables were collected. Ninety-three patients met inclusion criteria, with LifeFlight transferring 30 of them (32.3%). LifeFlight was more likely to initiate TTM compared to other EMS agencies (p=0.012), have run-sheets reported (p=0.001), and serve rural areas (p=0.036). LifeFlight was associated with more epinephrine (0.034) and norepinephrine (<0.001) use. Only 37% of IFTs had physician orders, with none (0.0%) of them defining vital sign targets. No difference in survival to discharge or CPC scores was observed between LifeFlight and other EMS agencies. No significant variation in comorbidities or vital signs was observed. There was no difference in survival to discharge or CPC scores between LifeFlight and ad hoc EMS agency. LifeFlight was associated with more TTM and vasopressor utilization during IFT. Most IFT encounters did not have dedicated physician orders, and none of the orders included vital sign targets.

Survival of out-of-hospital cardiac arrest patients admitted to the hospital during the Tokyo Summer Olympic and Paralympic Games in Japan

BackgroundThe influence of the Tokyo Summer Olympic/Paralympic Games on normal emergency medical system operations in Japan had not yet been fully elucidated. In this study, we examined whether out-of-hospital cardiac arrest (OHCA) patients treated during the Tokyo Olympic/Paralympic Games had differences in outcomes. MethodsUsing the nationwide JAAM-OHCA Registry, we evaluated the outcomes of OHCA patients admitted to the hospital during the Tokyo Olympic/Paralympic Games (July 23 to Aug. 8 and Aug. 24 to Sept. 5) in 2021, compared to those during same the dates in 2020 (Term 1: July 23 to Aug. 8 and Aug. 24 to Sept. 5), those during the pre-Olympic/Paralympic term during the same weekdays in the weeks before the event (Term 2: June. 18 to July. 4 and July. 6 to July. 18), and those during the post-Olympic/Paralympic term during the same weekdays in the weeks after the event (Term 3: Sept. 10 to Sept. 26 and Sept. 28 to Oct. 10). The primary outcome was 30-day survival, and multivariable logistic analysis was performed, adjusted for age and sex. ResultsA total of 3,111 OHCA patients were included in the study period (786 in the Olympic/Paralympic group, 774 in Term 1, 747 in Term 2, and 804 in Term 3). Crude 30-day survivals were 7.4% (58/786), 9.3% (72/774), 6.8% (51/747), and 8.2% (66/804), respectively. Using the Olympic/Paralympic group as a reference, multivariable logistic analysis revealed that 30-day survivals in Term 1 (OR 1.27 95% CI 0.88–1.83p = 0.20), Term 2 (OR 0.92 95% CI 0.62–1.36p = 0.67), and Term 3 (OR 1.10 95% CI 0.76–1.59p = 0.63) did not differ significantly. ConclusionsNo significant differences in 30-day survival for OHCA patients admitted during the Tokyo Summer Olympic/Paralympic Games were identified.

The association between serum free fatty acid levels and neurological outcomes in out-of-hospital cardiac arrest patients: A prospective observational study.

Free fatty acids (FFA) are a known risk factor in the development of sudden cardiac death. However, the relationship between FFA and the outcome of out-of-hospital cardiac arrest (OHCA) patients remains unclear. We aimed to examine the association between FFA and neurological outcomes in OHCA patients. This prospective observational study included adult (≥18 years) OHCA patients between February 2016 and December 2022. We measured serial FFA levels within 1 hour after ROSC and at 6, 12, 24, 48, and 72 hours after the return of spontaneous circulation (ROSC). The primary outcome was neurological outcome at 6 months. A poor neurological outcome was defined by cerebral performance categories 3, 4, and 5. A total of 147 patients were included. Of them, 104 (70.7%) had poor neurological outcomes, whereby the median FFA levels within 1 hour after ROSC (0.72 vs 1.01 mol/L), at 6 hours (1.19 vs 1.90 mol/L), 12 hours (1.20 vs 1.66 mol/L), and 24 hours (1.20 vs 1.95 mol/L) after ROSC were significantly lower than in good outcome group. The FFA levels at 6 hours (odds ratio, 0.583; 95% confidence interval, 0.370-0.919; P = .020), and 12 hours (odds ratio, 0.509; 95% confidence interval, 0.303-0.854; P = .011) after ROSC were independently associated with poor neurological outcomes. The lower FFA levels at 6 hours and 12 hours after ROSC were associated with poor neurological outcomes in patients with OHCA. FFA may reflect oxidative metabolism as well as oxidative stress.

The link between carotid artery stenosis and outcomes in patients with refractory out-of-hospital cardiac arrest

BackgroundMortality of out-of-hospital cardiac arrest (OHCA) remains high. Extracorporeal cardiopulmonary resuscitation (ECPR) has revolutionized OHCA treatment, but our understanding of the ECPR responder’s clinical profile is incomplete. Carotid artery stenosis (CAS) is a well-established cardiovascular disease risk factor. The impact of CAS on OHCA outcomes remains unelucidated. ObjectiveTo assess whether CAS burden affects the outcomes of OHCA patients treated with ECPR. MethodsThis study included patients with OHCA admitted for ECPR consideration, who had carotid ultrasonography performed. A numeric scale was applied to the plaque to create a CAS burden numeric scale. The primary outcome of the study was survival at discharge, compared among the different degrees of CAS. Neurologically intact survival and surrogate markers of neurologic injury were the secondary study endpoints. To assess the independent effect of CAS burden on survival to hospital discharge, we conducted a logistic regression analysis. ResultsBetween 2019 and 2023, carotid ultrasonography was performed on 163 patients who were admitted for refractory OHCA. CAS burden was equally distributed between the right and left carotid arteries. Logistic regression analysis indicated that the CAS burden was significantly associated with both overall and neurologically intact survival at discharge (p = 0.004). A linear relationship between the CAS burden and neuron-specific and S-100 levels was identified. Patients with normal carotids were significantly less likely to have encephalopathy on electroencephalograms. ConclusionCAS burden independently predicts the risk for worse survival and neurologic outcomes in patients suffering refractory OHCA who are treated with ECPR.

The Relationship between the Ratio of Urine Osmolality to Serum Osmolality and Neurological Outcomes in Out-of-hospital Cardiac Arrest Patients.

Progressive ischemic brain injury after cardiac arrest can cause damage to the hypothalamic-pituitary axis, particularly the pituitary gland. This may impact serum osmolality (SOsm) and urine osmolality (UOsm) in patients who have experienced out-of-hospital cardiac arrest (OHCA). We assumed that a low ratio of UOsm to SOsm (USR) is related to poor outcomes among OHCA patients. Therefore, the present study was designed to evaluate the association between the USR within 72 h after the restoration of spontaneous circulation (ROSC) and 6-month neurological outcomes in OHCA patients. This prospective, observational study included OHCA patients with targeted temperature management at Chonnam National University Hospital in Gwangju, Korea, between January 2016 and December 2022. We collected SOsm and UOsm data at admission (T0) and 24 (T1), 48 (T2), and 72 h (T3) after ROSC. The primary outcome was a poor neurological outcome at 6 months defined by cerebral performance categories 3, 4, or 5. This study included 319 patients. The mean UOsm and USRs at T0, T1, T2, and T3 of patients with poor outcomes were lower than those of patients with good outcomes. Multivariable analysis indicated that the USRs at T1 (odds ratio [OR], 0.363; 95% confidence interval [CI], 0.221-0.594), T2 (OR, 0.451; 95% CI, 0.268-0.761), and T3 (OR, 0.559; 95% CI, 0.357-0.875) were associated with a poor outcome. The areas under the receiver operating characteristic curves of USRs at T0, T1, T2, and T3 for predicting poor outcomes were 0.615 (95% CI, 0.559-0.669), 0.711 (95% CI, 0.658-0.760), 0.724 (95% CI, 0.671-0.772), and 0.751 (95% CI, 0.699-0.797), respectively. The USRs within 72 h of ROSC were associated with poor neurological outcomes at 6 months in OHCA patients.

Fluid balance during acute phase extracorporeal cardiopulmonary resuscitation and outcomes in OHCA patients: a retrospective multicenter cohort study.

The association between fluid balance and outcomes in patients who underwent out-of-hospital cardiac arrest (OHCA) and received extracorporeal cardiopulmonary resuscitation (ECPR) remains unknown. We aimed to examine the above relationship during the first 24 h following intensive care unit (ICU) admission. We performed a secondary analysis of the SAVE-J II study, a retrospective multicenter study involving OHCA patients aged ≥ 18 years treated with ECPR between 2013 and 2018 and who received fluid therapy following ICU admission. Fluid balance was calculated based on intravenous fluid administration, blood transfusion, and urine output. The primary outcome was in-hospital mortality. The secondary outcomes included unfavorable outcome (cerebral performance category scores of 3-5 at discharge), acute kidney injury (AKI), and need for renal replacement therapy (RRT). Overall, 959 patients met our inclusion criteria. In-hospital mortality was 63.6%, and the proportion of unfavorable outcome at discharge was 82.0%. The median fluid balance in the first 24 h following ICU admission was 3673 mL. Multivariable analysis revealed that fluid balance was significantly associated with in-hospital mortality (odds ratio (OR), 1.04; 95% confidence interval (CI), 1.02-1.06; p < 0.001), unfavorable outcome (OR, 1.03; 95% CI, 1.01-1.06; p = 0.005), AKI (OR, 1.04; 95% CI, 1.02-1.05; p < 0.001), and RRT (OR, 1.05; 95% CI, 1.03-1.07; p < 0.001). Excessive positive fluid balance in the first day following ICU admission was associated with in-hospital mortality, unfavorable outcome, AKI, and RRT in ECPR patients. Further investigation is warranted.

Prognostic value of arterial carbon dioxide tension during cardiopulmonary resuscitation in out-of-hospital cardiac arrest patients receiving extracorporeal resuscitation

BackgroundCurrent guidelines on extracorporeal cardiopulmonary resuscitation (ECPR) recommend careful patient selection, but precise criteria are lacking. Arterial carbon dioxide tension (PaCO2) has prognostic value in out-of-hospital cardiac arrest (OHCA) patients but has been less studied in patients receiving ECPR. We studied the relationship between PaCO2 during cardiopulmonary resuscitation (CPR) and neurological outcomes of OHCA patients receiving ECPR and tested whether PaCO2 could help ECPR selection.MethodsThis single-centre retrospective study enrolled 152 OHCA patients who received ECPR between January 2012 and December 2020. Favorable neurological outcome (FO) at discharge was the primary outcome. We used multivariable logistic regression to determine the independent variables for FO and generalised additive model (GAM) to determine the relationship between PaCO2 and FO. Subgroup analyses were performed to test discriminative ability of PaCO2 in subgroups of OHCA patients.ResultsMultivariable logistic regression showed that PaCO2 was independently associated with FO after adjusting for other favorable resuscitation characteristics (Odds ratio [OR] 0.23, 95% Confidence Interval [CI] 0.08–0.66, p-value = 0.006). GAM showed a near-linear reverse relationship between PaCO2 and FO. PaCO2 < 70 mmHg was the cutoff point for predicting FO. PaCO2 also had prognostic value in patients with less favorable characteristics, including non-shockable rhythm (OR, 3.78) or low flow time > 60 min (OR, 4.66).ConclusionPaCO2 before ECMO implementation had prognostic value for neurological outcomes in OHCA patients. Patients with PaCO2 < 70 mmHg had higher possibility of FO, even in those with non-shockable rhythm or longer low-flow duration. PaCO2 could serve as an ECPR selection criterion.

Retrospective Comparison of Upper and Lower Extremity Intraosseous Access During Out-of-Hospital Cardiac Arrest Resuscitation

Objective Intraosseous (IO) access is frequently utilized during the resuscitation of out-of-hospital cardiac arrest (OHCA) patients. Due to proximity to the heart and differential flow rates, the anatomical site of IO access may impact patient outcomes. Using a large dataset, we aimed to compare the outcomes of OHCA patients who received upper or lower extremity IO access during resuscitation. Methods The ESO Data Collaborative public use research datasets were used for this retrospective study. All adult (≥18 years of age) OHCA patients with successful IO access in an upper or lower extremity were evaluated for inclusion. Patients were excluded if they had intravenous (IV) access prior to IO access, or if they had a Do Not Resuscitate order documented. Our primary outcome was return of spontaneous circulation (ROSC). Secondary outcomes included survival to discharge and survival to discharge to home. Mixed-effects multivariable logistic regression models adjusted for age, sex, etiology, witnessed status, pre-first responder cardiopulmonary resuscitation (CPR), initial electrocardiogram (ECG) rhythm, location [private/residential, public, or assisted living/institutional], and response time in addition to the primary airway management strategy (endotracheal intubation, supraglottic device, surgical airway, no advanced airway) were used to compare the outcomes of patients with upper extremity IO access to the outcomes of patients with lower extremity IO access. Results After application of exclusion criteria, 155,884 patients who received IO access during resuscitation remained (76% lower extremity, 24% upper extremity). Upper extremity IO access was associated with greater adjusted odds of ROSC (1.11 [1.08, 1.15]), and this finding was consistent across multiple patient subgroups. Secondary analyses suggested that upper extremity access was associated with increased survival to discharge (1.18 [1.00, 1.39]) and survival to discharge to home (1.23 [1.02, 1.48]) in comparison to lower extremity IO access. Conclusion In this large prehospital dataset, upper extremity IO access was associated with a small increase in the odds of ROSC in comparison to lower extremity IO access. These data support the need for prospective investigation of the ideal IO access site during OHCA resuscitation.

Early coronary angioplasty fails to lower all-cause mortality in patients with out-of-hospital cardiac arrest without ST-segment elevation: A systematic review and meta-analysis.

Out-of-hospital cardiac arrest (OHCA) is defined as the loss of functional mechanical activity of the heart in association with an absence of systemic circulation, occurring outside of a hospital. Immediate coronary angiography (CAG) with percutaneous coronary intervention is recommended for OHCA with ST-elevation. We aimed to evaluate the effect of early CAG on mortality and neurological outcomes in OHCA patients without ST-elevation. This meta-analysis and systemic review was conducted as per principles of Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) group. A protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO, Ref No. = CRD42022327833). A total of 674 studies were retrieved after scanning several databases (PubMed Central, EMBASE, Medline, and Cochrane Central Register of Controlled Trials). A total of 18 studies were selected for the final analysis, including 6 randomized control trials and 12 observational studies. Statistically, there was no significant difference in primary outcome, i.e., mortality, between early and delayed CAG. In terms of the grade of neurological recovery as a secondary outcome, early and delayed CAG groups also showed no statistically significant difference. Early CAG has no survival benefits in patients with no ST elevations on ECG after OHCA.

Identifying the Barriers to Performing Dispatcher-assisted Bystander Cardiopulmonary Resuscitation in Out-of-hospital Cardiac Arrest

Background: Bystander cardiopulmonary resuscitation (BCPR) is critical for the survival of patients with out-of-hospital cardiac arrest (OHCA). This study aims to identify barriers to performing dispatcher-assisted bystander cardiopulmonary resuscitation (DA-BCPR) in patients with OHCA. Materials and Methods: This cross-sectional study was conducted on bystanders of 151 patients with OHCA who received emergency medical services (EMS) from June 2022 to June 2023 in Neyshabur City, Iran. The study data were collected using a questionnaire and telephone interviews. Data were analyzed using the chi-square test and Fisher exact test. P&lt;0.05 was considered statistically significant for all tests. Analyses were done using R software, version 4.0.1. Results: Of 151 patients, 18.92% were less than 50 years old and 68.92% were male. In 69% of cases, the arrival time of EMS was less than 10 min, and 84.46% of patients received BCPR at the scene. The most common barrier to performing DA-BCPR was “not recognizing a cardiac arrest and how to perform cardiopulmonary resuscitation (CPR)” (41.48%). It was reported that 38.35% of the bystanders were familiar with CPR. There was a significant relationship between the bystanders’ familiarity with CPR and performing DA-BCPR (P&lt;0.01). Conclusion: The most common barrier to performing DA-BCPR on patients with OHCA is the lack of knowledge and skills in bystanders. Improving bystanders’ knowledge and educating them about cardiac arrest, CPR, and DA-BCPR is critical to help them improve outcomes for OHCA patients.

Out-of-hospital cardiac arrest patients during the coronavirus disease 2019 pandemic

The coronavirus disease 2019 (COVID-19) pandemic had severe impact on the outcome of out-of-hospital cardiac arrest (OHCA) patients and the possibility of bystander cardiopulmonary resuscitation (CPR). Previous studies focused only on the short periods of the pandemic and reported a significant increase in the number of infections. In a retrospective cohort study we aimed to compare the outcomes of OHCA patients 1 year before and 1 year after the onset of COVID-19. Data of 519 OHCA patients during the pre-pandemic (January–December 2019; 262 patients) and intra-pandemic (April 2020–March 2021; 257 patients) periods in Yokohama Municipal Hospital, Japan were collected and analysed retrospectively. The study outcomes were the return of spontaneous circulation (ROSC), admission to hospital, survival to discharge, and cerebral performance category at discharge. The intra-pandemic period was associated with decreased bystander CPR (P = 0.004), prolonged transport time (P < 0.001), delayed first adrenaline administration (P < 0.001), and decrease in ROSC (P = 0.023). Logistic regression analysis revealed that the following factors were significantly associated with ROSC: “pandemic”, “shockable initial waveform”, and “witness presence”.

Comparing outcomes of out-of-hospital cardiac arrest patients with initial shockable rhythm in Singapore and Osaka using population-based databases

BackgroundPrevious research indicated outcomes among refractory out-of-hospital cardiac arrest (OHCA) patients with initial shockable rhythm were different in Singapore and Osaka, Japan, possibly due to the differences in access to extracorporeal cardiopulmonary resuscitation. However, this previous study had a risk of selection bias. To address this concern, this study aimed to evaluate the outcomes between Singapore and Osaka for OHCA patients with initial shockable rhythm using only population-based databases.MethodsThis was a secondary analysis of two OHCA population-based databases in Osaka and Singapore, including adult OHCA patients with initial shockable rhythm. A machine-learning-based prediction model was derived from the Osaka data (n = 3088) and applied to the PAROS-SG data (n = 2905). We calculated the observed-expected ratio (OE ratio) for good neurological outcomes observed in Singapore and the expected derived from the data in Osaka by dividing subgroups with or without prehospital ROSC.ResultsThe one-month good neurological outcomes in Osaka and Singapore among patients with prehospital ROSC were 70% (791/1,125) and 57% (440/773), and among patients without prehospital ROSC were 10% (196/1963) and 2.8% (60/2,132). After adjusting patient characteristics, the outcome in Singapore was slightly better than expected from Osaka in patients with ROSC (OE ratio, 1.067 [95%CI 1.012 to 1.125]), conversely, it was worse than expected in patients without prehospital ROSC (OE ratio, 0.238 [95%CI 0.173 to 0.294]).ConclusionThis study showed the outcomes of OHCA patients without prehospital ROSC in Singapore were worse than expected derived from Osaka data even using population-based databases.(249/250 words).

AMplitude Spectral Area (AMSA) is associated with one-year survival with good neurological outcome in out-of-hospital cardiac arrest

Abstract Background Patients resuscitated from Out-of-Hospital Cardiac Arrest (OHCA) with shockable rhythms are reported to have better survival rates. Amplitude spectral area (AMSA) of ventricular fibrillation (VF), a surrogate for the metabolic status of the myocardium, can predict shock success and return of spontaneous circulation (ROSC). There is minimal evidence regarding its role in predicting survival from OHCA, and the evidence that exists is limited to survival at discharge. Purpose To test the hypothesis that the first, the maximum, the minimum and the average values of AMSA are associated with one-year survival with good neurological outcome in OHCA patients. Methods All the OHCAs with at least one shockable rhythm, that occurred from January 2015 to December 2020 and collected from an Utstein-style database, were considered. AMSA values were calculated by retrospectively analyzing the data collected by the monitors/defibrillators used and by using a 2-second pre-shock ECG interval. The first, the maximum, the minimum and the average AMSA values during resuscitation were computed. Data were analyzed by using Cox regression analysis. Results 250 patients (84% male, median age 67 [57-77] years) with at least one computable AMSA value were included; 12% achieved ROSC and 9.4% survived at one year with good neurological outcome, defined as Cerebral Performance Category (CPC) ≤ 2. The first, the maximum, the minimum and the average values of AMSA were higher in patients alive one year after OHCA with CPC≤2 (first: 11.6 [9.9-14.7] vs 7.8 [5.1-11.8]; max: 15.4 [12-20] vs 9.9 [6.2-14.4]; min: 9.9 [8.5-12.2] vs 6.1 [4.3-9.6]; avg: 12.5 [10.7-15.2] vs 8.3 [5.5-12]; all p &amp;lt;0.01). These values showed similar areas under the curve of the receiver operating characteristic (ROC) curve for one-year survival with good neurological outcome (first: 0.77; max: 0.76; min: 0.78; avg: 0.78, p=ns). In univariable model, the survival probability with good neurological outcome was significantly lower in the first tertile (T1) of AMSA compared to the third one (T3; p&amp;lt;0.05; figure). In multivariable analysis, after correction for sex, presence of bystander CPR, age, EMS arrival time, witnessed status, OHCA location, the use of mechanical CPR and the total amount of epinephrine administrated, AMSA was significantly associated with probability of death or poor neurologic outcome [HR 0.5 (95%CI 0.3-0.9), p=0.03]. Conclusions This is the first study to evaluate the association between AMSA values and one-year survival with good neurological outcome. We found that AMSA is independently associated with one-year survival with­ good neurological outcome in OHCA patients and that the first, the maximum, the minimum and the average of AMSA values all have similar prediction power in survival rate with CPC≤2.

German Cardiac Arrest Registry (G-CAR): results of the pilot phase

Abstract Background/Introduction In Europe, over 30.000 persons per year suffer from out-of-hospital cardiac arrest (OHCA). Despite medical progress, survival rates with good neurological outcome remain low. For many important clinical issues, no or only insufficient evidence from randomised trials is available. Therefore, a systemic and standardised acquisition of the treatment course and of the outcome of OHCA patients is warranted. Purpose The German Cardiac Arrest Registry (G-CAR) is an observational, prospective, multicentre registry under the aegis of the German National Cardiac Society. It determines the characteristics, initial treatment strategies, invasive procedures, revascularisation therapies and the use of mechanical circulatory support devices with a focus on extracorporeal cardiopulmonary resuscitation (eCPR). It includes a prospective 12-month follow-up evaluating mortality, neurological outcomes and several patient-reported outcomes in the psychosocial domain, figure 1. Herein, we describe the first results of the pilot phase; more data will be available at the time of the ESC congress. Methods and Results In a pilot phase of 16 months, 15 national centres included 480 consecutive OHCA patients ≥18 years. Median age of the patients was 67 (interquartile range 57;76) years, 74.4% were male. 77.5% of the events were witnessed; bystander CPR was performed in 77.4%. Initial rhythm was shockable in 46.5%. 28.5% of the patients had ongoing CPR at hospital admission. eCPR was performed in 14.1% of the patients. Main presumed underlying causes of CPR were acute coronary syndromes and/or cardiogenic shock in 53.3% followed by primary arrhythmias (7.9%) and hypoxia (5.2%). In 35.2%, ST-segment elevations were observed after return of spontaneous circulation, mostly (62.1%) with an anterior location. In total, 66.6% of the patients underwent coronary angiography. In 71.5%, angiography was performed immediately, in 23.8% within 24 hours and in 4.7% in an elective setting. The LAD was the culprit lesion in 35.8%, the RCA in 17.7%, the LCX in 10.6% and the LM in 5.1%. In 30.3%, there was either no or an unclear culprit lesion. Regarding the strategy of percutaneous coronary intervention (PCI), culprit-only PCI was performed in 74.5%, multivessel PCI in 25.5%. Targeted temperature management was performed in 79.8%, with an invasive approach and non-invasive approach in approximately 50% each. In-hospital mortality was 69.2%, with anoxic brain damage being the main presumed cause of death (37.3%) followed by circulatory failure in 26.2%. Conclusions G-CAR is a multicenter German registry for adult OHCA patients including long-term follow-up. Primary aim is a better understanding of the determinants of acute and long-term outcomes with the perspective of an optimised treatment. Parallel to further in-depth analyses of the pilot phase including patient-reported outcomes, scaling up of G-CAR to a national level is envisaged.Registry flow-chartFirst results pilot phase G-CAR

Association of prehospital tracheal intubation with outcomes comparing to supraglottic airway device during out-of-hospital cardiac arrest by drowning: nationwide cohort study in Japan

Abstract Background/Introduction Drowning is the third leading cause of unintentional injury death, which causes more than 500,000 deaths annually worldwide. Several studies have examined the impact of tracheal intubation for outcomes in out-of-hospital cardiac arrest (OHCA) patients, however few studies examined it in OHCA patients by drowning. Purpose To compare survival outcomes among adults OHCA patients by drowning between tracheal intubation and supraglottic airway device. Methods This study compared the outcome of OHCA patients by drowning according to the airway management using Japanese nationwide, population-based registry (All-Japan Utstein Registry). From 2014 to 2020, consecutive adult OHCA patients were included. Patients who received tracheal intubation during cardiopulmonary resuscitation (CPR) were matched with patients treated with supraglottic airway device on the basis propensity scores in a 1:1 ratio, with a 0.2 caliper width. Propensity score was calculated by logistic regression model using following variables; year, prefectural preference of ETI use, age, sex, witnessed status, those who witnessed (By family, citizen, EMS, others), AED use, bystander-initiated CPR, prehospital involvement of physician, defibrillation by EMS, administration of adrenaline, time from call to CPR, first rhythm documented by EMS. The outcome measures were return of spontaneous circulation, survival at one month, and favorable neurological outcome defined as cerebral performance status 1 or 2. Results Of the 11, 703 eligible patients, 4467 (38.2%) and 7236 (61.8%) received tracheal intubation and supraglottic airway device during CPR, respectively. After propensity score matching, 3566 patients in each cohort were matched. The return of spontaneous circulation was higher in those with tracheal intubation compared with those with supraglottic airway device: 207/3566 (5.8%) versus 167/3566 (4.7%) (odds ratio 1.25, 95% confidence interval[CI] 1.02 to 1.55). There was no difference between the groups in one-month survival and favorable neurological outcome: 32/3566 (0.90%) versus 34/3566 (0.95%) (odds ratio 0.94, 95% CI 0.58 to 1.53), and 9/3566 (0.25%) versus 8/3566 (0.22%) (odds ratio 1.13, 95% CI 0.43 to 2.92), respectively. Conclusions In the propensity score matched study for adult OHCA by drowning, tracheal intubation was associated with the return of spontaneous circulation, whereas it was not associated with survival and favorable neurological outcome at one month compared to those with supraglottic airway device. Further studies such as to investigate the heterogeneity of the effect of intubation during the resuscitation might be mandated for the improvement of the outcome among the OHCA patients by drowning.Out-of-hospital cardiac arrest outcomes

Abstract 391: Association Between Defibrillation to Epinephrine Interval and Short-Term Outcomes in Out-of-Hospital Cardiac Arrest Patients With Shockable Rhythm

Background: The optimal timing of epinephrine administration after defibrillation in out-of-hospital cardiac arrest (OHCA) patients with shockable rhythm is unknown. Aim: We evaluated the association between defibrillation to epinephrine interval and short-term outcomes. Methods: Between 2011 and 2020, we enrolled 1,259,960 OHCA patients from a nationwide prospective population-based registry in Japan. After applying exclusion criteria, 20,905 patients with shockable rhythm as the first documented rhythm at emergency medical services (EMS) arrival who received epinephrine after defibrillation were eligible for the study. Clinical outcomes included prehospital return of spontaneous circulation (ROSC), survival, and favorable neurological outcome at 30 days. To examine whether each variable predicted a good short-term outcome, multivariable logistic regression models were constructed using age, gender, year, district, origin of cardiac arrest, witnessed arrest, bystander-initiated cardiopulmonary resuscitation, call to EMS arrival interval, EMS arrival to defibrillation interval, and defibrillation to epinephrine interval. Results: At 30 days, 1,618 patients (8%) had a favorable neurological outcome. The defibrillation to epinephrine interval in these patients was significantly shorter than the interval in patients with an unfavorable neurological outcome [8 (5-12) vs 11 (7-16) min; P&lt;0.001]. The proportion of patients who achieved prehospital ROSC, survived, or had a favorable neurological outcome at 30 days decreased as time to epinephrine after defibrillation increased (P&lt;0.001 for trend). Multivariable analysis showed that shorter defibrillation to epinephrine interval independently predicted good outcomes ( Table ). Conclusion: A shorter defibrillation to epinephrine interval is significantly associated with good short-term outcomes in OHCA patients with shockable rhythm.