Prehospital Cardiac Arrest Patients Research Articles

Does the Use of Auto-Transfusion Tourniquet (A-TT) during CPR Drill Influence its Quality Parameters?

The Auto-Transfusion Tourniquet (A-TT®) shifts the blood from the legs to the central circulation and blocks its return to the legs. The use of the A-TT has previously been shown to be effective during CPR and was shown in a pig study [1] to increase systolic and diastolic blood pressures, coronary perfusion pressure, cerebral perfusion and end-tidal PCO2. The present study was done to assess if using the A-TT as part of CPR protocol in pre-hospital cardiac arrest patients treated by a team of 4 caregivers interferes with the quality parameters of the CPR.

The success rate of cardiopulmonary resuscitation and its correlated factors in patients with emergency prehospital cardiac arrest

ABSTRACT To assess the initial success rate and its correlated factors on cardiopulmonary resuscitation (CPR) in emergency prehospital cardiac arrest patients. The clinical information of 429 patients with cardiac arrest who underwent prehospital CPR in the fourth hospital of Hebei Medical University from Jan 2020 to Apr 2022 were evaluated. The patients were divided into the successful group (ROSC, n = 25) and the unsuccessful group (non-ROSC, n = 404) according to whether the autonomous circulation (ROSC) was resumed. The univariate analysis was performed to evaluate the differences in age, the start time of CPR, the application of electric defibrillation, and other related data between the two groups. The multivariate analysis evaluated protective factors affecting CPR’s success in prehospital cardiac arrest patients. Patients with cardiogenic causes had the highest success rate of cardiopulmonary resuscitation. The causes of traffic accidents and drowning account for a low proportion. Furthermore, the median CPR length was 25.0 min, alternating from 1.5 to 64 mi. The univariate analysis revealed that age, the start time of CPR, application of electric defibrillation, and adrenaline dosage were correlated with CPR attempts (p < 0.05). Multivariate logistic regression analysis showed that the age of patients with prehospital CA, the location of prehospital CA, etiology, bystander CPR, CPR start time, defibrillation start time, tracheal intubation time, type of rhythm before resuscitation, adrenaline dosage <5 mg, and adrenaline administration time were all the influencing factors of prehospital CPR success (p < 0.01). The factors affecting CPR’s success rate in prehospital CA patients are complicated. Establishing a few procedures to diminish the incidence of these risk factors is crucial.

1039: ON THIN ICE? REEVALUATING THE CLINICAL NEED FOR ENDOVASCULAR COOLING CATHETERS IN POST-ROSC CARE

Introduction: Targeted temperature management (TTM) is a widely practiced standard of care in post-cardiac arrest patients. Methods can include standard external cooling devices (SECD) and endovascular cooling catheters (ECC). Recent literature suggests that hypothermia is nonsuperior to normothermic therapy in reducing mortality amongst post-cardiac arrest patients. In a post-hoc analysis, ECCs were superior in achieving and maintaining target temperatures compared with SECDs. We aimed to re-examine the clinical benefit of using ECCs compared to SECDs in TTM of pre-hospital cardiac arrest patients in a real life clinical setting in an attempt to standardize provider practice in our institution. Methods: 116 patients presenting to the ED across 2019 suffering a pre-hospital cardiac arrest were retrospectively identified. Charts were separated into three groups: ECCs, alternative cooling methods, or no cooling and examined for temperature maintained over a 48 hour period after TTM initiation or admission, length of ICU stay, complications rates, and 28-day mortality. Kruskal Wallis test was used to detect a significant difference in mean temperature. Secondary outcomes were compared using independent sample t-tests. Results: 103 charts were analyzed and 13 charts removed for incomplete data. There was a statistically significant difference in maintenance of target temperature > 24 hours between patients in the “ECC group” compared to the “no cooling” and “alternative cooling methods” groups (p=< 0.0001). We found no significant differences in length of hospital stay (p=0.730), and overall mortality (p=0.881) between the three groups (p=0.881). Mean indwelling catheter time was one day. Complications included arterial puncture (n=1) in the ECC group. Conclusions: This retrospective study supports current literature suggesting superior TTM by ECCs. However, ECCs pose no significant benefit in reducing the length of ICU stay or decreasing mortality compared to standard methods, consistent with prior prospective studies. With the lack of significant survival benefits and increased risk of complications, the usage of ECCs may be more harmful than beneficial. The clinical merits of ECCs must be questioned and noninvasive measures should be considered more readily.

Retrospective Comparison of Prehospital Sustained Return of Spontaneous Circulation (ROSC) Rates Within a Single Basic Life Support Jurisdiction Using Manual vs Lund University Cardiac Assist System (LUCAS-2) Mechanical Cardiopulmonary Resuscitation.

ObjectiveSeveral studies have examined the impact of mechanical cardiopulmonary resuscitation (CPR) devices among multi-jurisdictional emergency medical services (EMS) systems; however, the variability across such systems can inject bias and confounding variables. We focused our investigation on the effect of introducing the Lund University Cardiac Assist System 2 (LUCAS-2) into a single basic life support (BLS) fire department first response jurisdiction served by a single private advanced life support (ALS) agency, hypothesizing that the implementation of the device would increase prehospital return of spontaneous circulation (ROSC) rates as compared with manual CPR. MethodsA retrospective observational analysis of adult non-traumatic prehospital cardiac arrest ALS agency records was conducted. Descriptive statistics were computed, and logistic regression was used to assess the impact of CPR method, response time, age, gender, CPR initiator, witnessed status, automated external defibrillator (AED) initiator, and presence of an initial shockable rhythm on ROSC rates. A Chi-square analysis was used to compare ROSC rates among compression modalities both before and after the implementation of LUCAS-2 on July 1, 2011. ResultsFrom an initial dataset of 857 cardiac arrest records, only 264 (74 pre-LUCAS period, 190 LUCAS-2 period) met inclusion criteria for the primary objective. The ROSC rates were 29.7% (22/74) and 29.5% (56/190), respectively, for manual-only and LUCAS-assisted CPR (p=0.9673). Logistic regression revealed a significant association between ROSC and two of the independent variables: arrest witnessed (OR 3.104; 95% CI 1.896-5.081; p<0.0001) and initial rhythm shockable (OR 2.785; 95% CI 1.492-5.199; p<0.0013). ConclusionsAnalyses support the null hypothesis that there is no difference in prehospital ROSC rates among adult non-traumatic cardiac arrest patients when comparing mechanical-assisted and manual-only CPR. These results are consistent with other larger multi-jurisdictional mechanical CPR studies. Systems with limited personnel might consider augmenting their resuscitations with a mechanical CPR device, although cost and system design should be factored into the decision. Secondary analysis of independent variables suggests that prehospital cardiac arrest patients with a witnessed arrest or an initial rhythm that is shockable have a higher likelihood of attaining ROSC. The power of our primary objective was limited by the sample size. Additionally, we were not able to adequately assess the quality of CPR among the two comparison groups with a lack of consistent end-tidal carbon dioxide (EtCO2) data.

Gender and location disparities in prehospital bystander AED usage

BackgroundWith bystander AED usage being critical for prehospital cardiac arrest patient outcomes, it is important to analyze if the gender and location disparities found in bystander CPR rates also exist for bystander AED usage. MethodsUsing the National Emergency Medical Services Information System (NEMSIS) database, 1,144,969 bystander AED cases were analyzed on the basis of gender and location. Chi-squared testing checked for statistical significance and effect size was measured using relative risk (RR). ResultsUsing female patients as a baseline, the RR for bystander AED usage for male patients was 1.34 (95% CI [1.3310, 1.3557], p < 0.001) indicating male patients are 34% more likely to receive bystander AED usage compared to female patients. Analyzing bystander AED usage per urbanity region using urban patients as a baseline, resulted in a RR of 0.87 for suburban patients (95% CI [0.8572, 0.8833], p < 0.001), 0.39 for rural patients (95% CI [0.3849, 0.3971], p < 0.001), and 0.36 for frontier patients (95% CI [0.3515, 0.3726], p < 0.001) showing a sharp decline in the chance of bystander AED usage in rural and frontier areas. ConclusionsFemale patients are less likely to receive bystander AED usage compared to male patients. To resolve these disparities increased public awareness is necessary that supports AED usage on females as socially acceptable and necessary for patient outcomes. Furthermore, given bystander AED usage among males and females declined as cardiac arrest locations became more remote, improvements in rural and frontier AED availability and training are necessary to increase bystander AED usage rates in those regions.

Prehospital Disposition and Patient Outcomes in Cardiac Arrest AFTER Resuscitation Termination Protocol Change in an Urban Setting.

Out-of-hospital cardiac arrest (OHCA) is a leading cause of death in the United States, and efforts have been made to develop termination of resuscitation protocols utilizing clinical criteria predictive of successful resuscitation and survival to discharge. A termination of resuscitation protocol utilizing longer resuscitation time and end-tidal carbon dioxide (EtCO2) monitoring criteria for termination was implemented for Emergency Medical Service (EMS) providers in an urban prehospital system in 2017. This study examines the effect the modified termination of resuscitation protocol had on rates of patient transport to a hospital, return of spontaneous circulation (ROSC), and survival to discharge. A retrospective analysis was performed utilizing data from the Cardiac Arrest Registry to Enhance Survival (CARES) database. A total of 1,005 prehospital cardiac arrest patients 18 years and older from 2016 through 2017 were included in the analysis. Patients with traumatic cardiac arrest or had valid do-not-resuscitate orders were excluded. Unadjusted analysis using chi-square statistics was performed, including an analysis stratified by Utstein style reporting. Adjusted analysis was also performed using logistic regression with multiple imputation for missing values. Unadjusted analysis showed a significant decrease in ROSC on emergency department (ED) arrival (30% versus 13%; P <.001) following the change in protocol. There was no significant difference in patient transport rate (62%) and a statistically non-significant decrease in overall survival (15% versus 11%). When stratified by Utstein style analysis, statistically significant decreases in ED arrival with ROSC were seen for unwitnessed asystolic, as well as bystander witnessed asystolic, pulseless electrical activity (PEA), and shockable OHCA. Adjusted analysis showed a decreased likelihood of ROSC with the protocol change (0.337; 95% CI, 0.235-0.482). The modification of termination of resuscitation protocol was not associated with a statistically significant change in transport rate or survival. A significant decrease in rate of arrivals to the ED with ROSC was seen, particularly for bystander witnessed OHCA.

Questionnaire for Hiroshima-city emergency bureau about pre-hospital cardiac arrest patients requested do-not-attempt-resuscitation

Questionnaire for Hiroshima-city emergency bureau about pre-hospital cardiac arrest patients requested do-not-attempt-resuscitation

A novel technique to assess the quality of ventilation during pre-hospital cardiopulmonary resuscitation

BackgroundDevices that measure ventilation in the pre-hospital setting are deficient especially during early cardiopulmonary resuscitation (CPR) before placement of an advanced airway. Consequently, evidence is limited regarding the role of ventilation during early CPR and its effect on outcomes. ObjectiveTo develop software that automatically identifies ventilation waveforms recorded by defibrillators based on changes in transthoracic impedance during standard CPR. MethodsThis was an observational, retrospective analysis of non-traumatic pre-hospital cardiac arrest patients who received 30:2 CPR by emergency medical service rescuers. Data was collected from 550 cases recorded by the bioimpedance channel of defibrillators. Two expert clinicians independently assessed all episodes from the time of initial CPR until placement of an advanced airway, defined acceptable ventilation waveforms, and annotated the pauses between compressions with ventilation waveforms. We then developed software that incorporated the expert criteria and automatically annotated pauses with acceptable ventilations. ResultsA total of 7396 pauses were analyzed, mean(SD) duration of 30:2 CPR was 13 (8) min, with 13 (10) pauses/patient, and mean pause duration of 6 (3) s. Reviewer 1 and reviewer 2 identified 2375 and 2249 pauses with any acceptable ventilation, respectively, with an inter-rater reliability of 0.94. The novel software program reproduced expert annotation with excellent agreement (>0.8) and high accuracy, both sensitivity and specificity above 90%, compared to two reviewers. The software presented a substantial agreement with the reviewers (κ > 0.73) for ventilation counts in the pauses. ConclusionWe developed a novel and reliable strategy that enables investigation of ventilation quality during standard CPR using thoracic bioimpedance. This strategy would allow a timely and reliable automatic annotation of large scale resuscitation datasets.

P003: Which factors predict resuscitation outcomes in patients arriving to the emergency department in cardiac arrest? A SHoC series study

Introduction: The decision as to whether to end resuscitation for pre-hospital cardiac arrest (CA) patients in the field or in the emergency department (ED) is commonly made based upon standard criteria. We studied the reliability of several easily determined criteria as predictors of resuscitation outcomes in a population of adults in CA transported to the ED. Methods: A retrospective database and chart analysis was completed for patients arriving to a tertiary ED in cardiac arrest, between 2010 and 2014. Patients were excluded if aged under 19. Multiple data were abstracted from charts using a standardized form. Regression analysis was used to compare criteria that predicted return of spontaneous circulation (ROSC) and survival to hospital admission (SHA). Results: 264 patients met the study inclusion criteria. Logistic regression was used to identify predictors of ROSC and SHA. The criteria that emerged as significant predictors for ROSC included; longer ED resuscitation time (Odds ratio 1.11 (1.06- 1.18)), witnessed arrest (Odds ratio 9.43 (2.58- 53.0)) and having an initial cardiac rhythm of Pulseless Electrical Activity (Odds Ratio 3.23 (1.07-9.811)) over Asystole. Receiving point of care ultrasound (PoCUS; Odds ratio 0.22 (0.07-0.69)); and having an initial cardiac rhythm of Pulseless Electrical Activity (Odds Ratio 4.10 (1.43-11.88)) were the significant predictors for SHA. Longer times for ED resuscitation was close to reaching significance for predicting SHA Conclusion: Our results suggest that both fixed and adaptable factors, including increasing resuscitation time, and PoCUS use in the ED were important independent predictors of successful resuscitation. Several commonly used criteria were unreliable predictors.

Use of Supraglottic Airway Devices by Paramedics in the Management of Adult Prehospital Cardiac Arrest Patients

Introduction Current best practice for paramedic airway management of prehospital cardiac arrest is being continually reviewed following changes to the emphasis on intubation as a primary intervention within international resuscitation guidelines. Subsequently, there is increased enthusiasm for the use of next generation supraglottic airway devices. This review aimed to identify the current evidence for the safety and effectiveness of supraglottic airways for the management of prehospital cardiac arrest. Methods A search of the electronic databases Medline, PubMed, Science Direct and Cochrane Library was conducted. Papers were excluded if they did not examine airway management in the prehospital cardiac arrest setting, involved the use of sedative or paralysing agents, involved paediatric patients, animals or cadavers. Results Of the 689 articles identified, 22 peer-reviewed articles were included for analysis. All 22 articles were from the following countries: United States of America, United States of America and Canada, Australia, Austria, Finland, Germany, Korea, Japan, The Netherlands, Norway, Taiwan and the United Kingdom. Discussion This review revealed large variances in both device effectiveness and patient outcome, particularly between geographical locations. Second-generation supraglottic airway devices demonstrated considerable improvement in effectiveness over their predecessors. Interestingly, the use of bag-valve mask ventilation reported better outcomes than any other form of advanced airway intervention. Studies also highlighted the diversity of airway management techniques and devices across global EMS systems. Conclusion Despite favourable indications of the effectiveness and safety of the next generation supraglottic airway devices, the paucity of pre-hospital specific research (particularly randomised controlled trials) challenges decision-making regarding pre-hospital airway management best practice.

Airway Management for Adults with Prehospital Cardiac Arrest: Is Intubation Passé?

To compare outcomes for prehospital cardiac arrest patients whose airways are managed with endotracheal intubation or insertion of a supraglottic

Pre- and postconditioning effect of Sevoflurane on myocardial dysfunction after cardiopulmonary resuscitation in rats

Post-resuscitation myocardial dysfunction is an important cause of death in the intensive care unit after initially successful cardiopulmonary resuscitation (CPR) of pre-hospital cardiac arrest (CA) patients. Volatile anaesthetics reduce ischaemic–reperfusion injury in regional ischaemia in beating hearts. This effect, called anaesthetic-induced pre- or postconditioning, can be shown when the volatile anaesthetic is given either before regional ischaemia or in the reperfusion phase. However, up to now, little data exist for volatile anaesthetics after global ischaemia due to CA. Therefore, the goal of this study was to clarify whether Sevoflurane improves post-resuscitation myocardial dysfunction after CA in rats.Following institutional approval by the Governmental Animal Care Committee, 144 male Wistar rats (341±19g) were randomized either to a control group or to one of the 9 interventional groups receiving 0.25 MAC, 0.5 MAC or 1 MAC of Sevoflurane for 5min either before resuscitation (SBR), during resuscitation (SDR) or after resuscitation (SAR). After 6min of electrically induced ventricular fibrillation CPR was performed. Before CA (baseline) as well as 1h and 24h after restoration of spontaneous circulation (ROSC), continuous measurement of ejection fraction (EF), and preload adjusted maximum power (PAMP) as primary outcome parameters and end systolic pressure (ESP), end diastolic volume (EDV) and maximal slope of systolic pressure increment (dP/dtmax) as secondary outcome parameters was performed using a conductance catheter.EF was improved in all Sevoflurane treated groups 1h after ROSC in comparison to control, except for the 0.25 MAC SDR and 0.25 MAC SAR group (0.25 MAC SBR: 38±8, p=0.02; 0.5 MAC SBR: 39±7, p=0.04; 1 MAC SBR: 40±6, p=0.007; 0.5 MAC SDR: 38±7, p=0.02; 1 MAC SDR: 40±6, p=0.006; 0.5 MAC SAR: 39±6, p=0.01; 1 MAC SAR: 39±6, p=0.002, vs. 30±7%). Twenty-four hours after ROSC, EF was higher than control in all interventional groups (p<0.05 for all groups). EF recovered to baseline values 24h after ROSC in all SBR and SAR groups. PAMP was improved in comparison to control (4.6±3.0mW/μl2) 24h after ROSC in 0.5 MAC SBR (9.4±6.9mW/μl2, p=0.04), 1 MAC SBR (8.9±4.4mW/μl2, p=0.04), 1 MAC SDR (8.0±5.7mW/μl2, p=0.04), and 1 MAC SAR (7.3±3.5mW/μl2, p=0.04). ESP, EDV, and dP/dtmax was not different from control 1h as well as 24h after ROSC with the exception of 1 MAC SDR with a reduced ESP 1h after ROSC (89±16 vs. 103±22mmHg, p=0.04). Sevoflurane treatment did not affect survival rate.This animal study of CA and resuscitation provides the hypothesis that pharmacological pre- or postconditioning with the volatile anaesthetic Sevoflurane – administered before CA, during resuscitation or after ROSC – results in an improved myocardial inotropy 24h after ROSC. Sevoflurane treatment seems to improve EF even in the early phase of reperfusion 1h after ROSC. Therefore further targeted studies on the optimal dose and time point of administration of Sevoflurane in cardiopulmonary resuscitation seem to be worthwhile (Institutional protocol number: 35-9185.81/G-24/08).

Start value of cerebral saturation in pre-hospital cardiac arrest patients: does it mean something?

Start value of cerebral saturation in pre-hospital cardiac arrest patients: does it mean something?

Start value of cerebral saturation in prehospital cardiac arrest patients: does it mean something?

During cardiopulmonary resuscitation (CPR) monitoring possibilities are limited. Parnia and colleagues investigated the feasibility and role of near-infrared spectroscopy (NIRS) during CPR in cardiac arrest patients (CA) [1]. NIRS could have a role in predicting return of spontaneous circulation (ROSC). Recently, the Equanox® with four wavelengths sensor was validated to provide absolute data on regional cerebral saturation [2]. We measured cerebral oxygenation (rSO2) during CPR with NIRS technology and analyzed the differences between initial cerebral saturations in patients achieving ROSC compared with patients without ROSC.

No Return of Pulses in the Field Portends Dismal Survival

Prehospital cardiac arrest patients who do not achieve return of spontaneous circulation (ROSC) continue to be transported to the hospital despite the

Pro cardiopulmonary resuscitation before defibrillation

The medical dogma has always been to defibrillate a patient discovered to be in ventricular fibrillation (VF), and automatic electric defibrillators (AED) drove this standard into widespread cardiopulmonary resuscitation (CPR) guidelines. Slow AED operation and three stacked shocks added several minutes of not providing blood flow generated by chest compressions. Investigators questioned the practice of providing defibrillation first for patients with longer down time compared to providing chest compressions prior to defibrillation. Human and experimental literature in addition to the interplay between chest compression, defibrillation, and saving lives are discussed. The experimental and human literature published regarding chest compression prior to defibrillation is reviewed, the importance of providing chest compressions that generate adequate blood flow to vital organs is highlighted, and the scientific evidence for CPR before defibrillation was performed is explored. Our review documented that in experimental animal studies of cardiac arrest there is a pooling of blood on the venous side of the heart during VF and that chest compression before defibrillation serve two purposes: (1) high quality chest compressions preserve brain function and (2) perfusing the heart with blood,“primes it” for successful restoration of spontaneous circulation. In clinical practice, the time interval of CPR before defibrillation is unknown. One randomized trial of 3 min of CPR before defibrillation found a significant increase in survival for those who were reached more than 5 min after cardiac arrest, and this was supported by a study based on historic controls. Other studies have not found any benefit but we may speculate that this was due to the quality of the CPR. Delaying defibrillation attempts is meaningless, if quality of chest compressions is suboptimal. High quality CPR before defibrillation is the treatment of choice for those patients who will not receive a defibrillation attempt shortly after VF started. Regarding survival, it has not been documented that CPR first is inferior to defibrillation first. CPR first is safe and effective for most prehospital cardiac arrest patients.

Excessive chest compression rate is associated with insufficient compression depth in prehospital cardiac arrest

Background and goal of studyThe relationship between chest compression rate and compression depth is unknown. In order to characterise this relationship, we performed an observational study in prehospital cardiac arrest patients. We hypothesised that faster compressions are associated with decreased depth. Materials and methodsIn patients undergoing prehospital cardiopulmonary resuscitation by health care professionals, chest compression rate and depth were recorded using an accelerometer (E-series monitor-defibrillator, Zoll, USA). Compression depth was compared for rates <80/min, 80–120/min and >120/min. A difference in compression depth ≥0.5cm was considered clinically significant. Mixed models with repeated measurements of chest compression depth and rate (level 1) nested within patients (level 2) were used with compression rate as a continuous and as a categorical predictor of depth. Results are reported as means and standard error (SE). Results and discussionOne hundred and thirty-three consecutive patients were analysed (213,409 compressions). Of all compressions 2% were <80/min, 62% between 80 and 120/min and 36% >120/min, 36% were <4cm deep, 45% between 4 and 5cm, 19% >5cm. In 77 out of 133 (58%) patients a statistically significant lower depth was observed for rates >120/min compared to rates 80–120/min, in 40 out of 133 (30%) this difference was also clinically significant. The mixed models predicted that the deepest compression (4.5cm) occurred at a rate of 86/min, with progressively lower compression depths at higher rates. Rates >145/min would result in a depth <4cm. Predicted compression depth for rates 80–120/min was on average 4.5cm (SE 0.06) compared to 4.1cm (SE 0.06) for compressions >120/min (mean difference 0.4cm, P<0.001). Age and sex of the patient had no additional effect on depth. ConclusionsThis study showed an association between higher compression rates and lower compression depths. Avoiding excessive compression rates may lead to more compressions of sufficient depth.

Abstract 17087: Doubled Survival From Out-of-Hospital Cardiac Arrest in a Rural Community in North-Norway Following Implementation of an Aggressive Chest Pain Protocol with Early Prehospital Thrombolysis for STEMI

Introduction Survival from prehospital cardiac arrest (PCA) remains low. Tromsø municipality in rural North-Norway has a mixed urban-rural population of 60.000, good ground and air ambulance systems, short response times, and dispatch centres staffed with nurses and paramedics, all loyal to current guidelines. Hypothesis By changing focus from the onset of ‘ collapse ’ in PCA to the onset of chest pain in acute coronary syndrome, we hypothesized that more PCA-patients could survive by saving time to alarm, dispatch, diagnosis and first defibrillation. We started an aggressive criteria based prehospital chest pain protocol in 2000. Local GPs and ambulance paramedics were trained in symptoms and signs of STEMI, to access and transmit prehospital 12-leads ECG, give MONA as well as early prehospital thrombolysis (PHT) to patients with prehospital diagnosed acute STEMI. We applied defibrillation pads to all chest pain. The population was informed through media stunts. Methods Retrospective study of survival from PCA during two 5-years periods in Tromsø (1999 -2004; 2004-2009). Each PCA patient's Utstein-chart, digital dispatch centre logs, hospital records and non-survivors autopsy reports were analysed. Results Annual incidence of PCA with resuscitation attempts and ambulance dispatched was 45,3 pr. 100.000. During first 5-years, 10,5 % of all patients (18/172) with PCA were discharged alive. During second period, survival to discharge doubled to 22,3 % (31/139, p&lt;0,05). Presence of an initial shockable rhythm (VF/VT) increased significantly. In patients with witnessed PCA of cardial etiology and a shockable first rhythm, survival to discharge was 21,4 % during the first 5-years period, but doubled to 44,2 % (19/43, p&lt;0,05) in the second period. CPR was started by lay bystanders prior to ambulance arrival in 68,2 % of patients during first, increasing to 76,3 % during the second study period (NS). Prehospital ambulance response time was unchanged at 10 min in each period. By moving system attention ‘to the left of cardiac arrest’, survival to discharge doubled.

Paramedics successfully perform humeral EZ-IO intraosseous access in adult out-of-hospital cardiac arrest patients

ObjectiveStudies on humeral placement of the EZ-IO (Vidacare, Shavano Park, TX, USA) have shown mixed results. We performed a study to determine the first-attempt success rate at humeral placement of the EZ-IO by paramedics among prehospital adult cardiac arrest patients. MethodsA retrospective cohort analysis of data prospectively collected over a 9-month period. Data are a subset extracted from a prehospital cardiac arrest study. The cohort consisted of adult cardiac arrest patients in whom the EZ-IO placement was attempted in the humerus by paramedics. Choice of vascular access was at the discretion of the paramedic; options included tibial or humeral EZ-IO and intravenous. Primary outcome is the percentage of successful placements (stable, flow, without extravasation) on first attempt. Secondary outcomes are overall successful placement, complications, and reason for failure. Data were collected during a post–cardiac arrest interview. ResultsHumeral intraosseous (IO) access was attempted in 61% (n = 247) of 405 cardiac arrests evaluated with mean age of 63 (±16) years, 58% male. First-attempt successful placement was 91%. Successful placement was 94%, considering the second attempts. In the unsuccessful attempts, 2% reported obesity as the cause, 1% reported stable placement without flow, and 2% reported undocumented causes for failure. There were also 2% reports of successful placement with subsequent dislodgement. ConclusionsThe results of this study suggest a high degree of paramedic proficiency in establishment of IO access in the proximal humerus of the out-of-hospital cardiac arrest. Few complications suggest that proximal humeral IO access is a reliable method for vascular access in this patient population.

Excessive chest compression rate is associated with insufficient compression depth in out-of-hospital cardiac arrest

Background and goal of study: In the latest Consensus on Science and Treatment Recommendations on Cardiopulmonary Resuscitation (ref), the relationship between compression rate and compression depth is considered to be a knowledge gap. In order to characterize this relationship, we performed an observational study in pre-hospital cardiac arrest patients. Materials and methods : In patients undergoing out-of-hospital cardiopulmonary resuscitation by health care professionals, chest compression rate and depth were recorded using an accelerometer (E-series monitor-defibrillator, Zoll, USA). The monitor provided real-time corrective feedback for compression rates 120/min. A difference in compression depth ≥5 mm was considered potentially clinically significant. Results and discussion : Thirty-one consecutive patients were analyzed (50375 compressions, on average 1625 per patient). Of all compressions 2% were 120/min. Mean compression depth for rates 80-120/min was 4.5 cm (SD=1) compared to 3.5 cm (SD=1) for compressions >120/min (P 120/min compared to rates 80-120/min, in 10 out of 31 (32%) this difference was also clinically significant. There was no difference between the mean depth of compressions <80/min and the mean depth of compressions 80-120/min. Conclusions : Compression rates >120/min were associated with a lower compression depth. The observation that compression depth is lower with increased compression rates underscores the importance of feedback on rate during CPR. Reference Nolan JP, Hazinski MF, Billi JE, Boettiger BW, et al. Executive Summary 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 2010; 81S: e1-e25.