Prehospital Return Of Spontaneous Circulation Research Articles

Abstract 168: Association Between Prehospital Advanced Airway Management for Pediatric Out-of-Hospital Cardiac Arrest and Survival

Introduction: It is unclear whether prehospital advanced airway management (AAM: endotracheal intubation and supraglottic airway device placement) for pediatric patients with out-of-hospital cardiac arrest (OHCA) improves patient outcomes. Objective: To test the hypothesis that prehospital advanced airway management during pediatric OHCA is associated with patient outcomes. Methods: We conducted a secondary analysis of a nationwide, prospective, population-based OHCA registry in Japan. We included pediatric patients (<18 years) with OHCA in whom emergency medical services (EMS) personnel resuscitated and transported to medical institutions during 2014 and 2015. The primary outcome was one-month survival. Secondary outcome was one-month survival with favorable functional outcome, defined as cerebral performance category score 1 or 2. Patients who received AAM during cardiopulmonary resuscitation by EMS personnel at any given minute were sequentially matched with patients at risk of receiving AAM within the same minutes based on time-dependent propensity score calculated from a competing risk regression model in which we treated prehospital return of spontaneous circulation as a competing risk event. Results: We included 2,548 patients; 1,017 (39.9%) were infants (<1 year), 839 (32.9%) were children (1 year to 12 years), and 692 (27.2%) were adolescents. Of the 2,548, included patients, 336 (13.2%) underwent prehospital AAM during cardiac arrest. In the time-dependent propensity score matched cohort (n = 642), there were no significant differences in one-month survival (AAM: 32/321 [10.0%] vs. no AAM: 27/321 [8.4%]; odds ratio, 1.33 [95% CI, 0.80 to 2.21]) and one-month survival with favorable functional outcome (AAM: 6/321 [1.9%] vs. no AAM: 5/321 [1.6%]; odds ratio, 1.48 [95% CI, 0.41 to 5.40]). Conclusions: Among pediatric patients with OHCA, we found no associations between prehospital AAM and favorable patient outcomes.

Abstract 317: The Clinical Features and Outcomes of Vasospastic Angina in Patients Survived Out-of-Hospital Cardiac Arrest

Introduction: Acute myocardial infarction (AMI) is a major cause of cardiac arrest. Coronary vasospasm has been suggested to play a significant role in the acute phase of MI. Vasospastic angina (VSA) is characterized by spontaneous attacks of chest pain, caused by transient coronary vasospasm. Severe coronary vasospasm might cause AMI, fatal arrhythmia, and subsequent cardiac arrest, however, there have been limited studies about the clinical characteristics and prognosis of patients with VSA regarding cardiac arrest. This study investigated the clinical features and outcomes of VSA compared to other MI in patients survived out-of-hospital cardiac arrest (OHCA). Method and Results: We analyzed the data of adult OHCA patients from the prospectively collected post cardiac arrest syndrome (PCAS) registry of 3 urban academic hospitals from December 2013 to December 2017. During the study period, 721 OHCAs were collected, including 18 diagnosed with VSA and 133 with other MI as primary cause of cardiac arrest. Compared to other MI, more patients achieved pre-hospital return of spontaneous circulation (ROSC) in VSA group (72.2% vs. 47.4%, p =0.041). The advanced cardiovascular life support (ACLS) time (median, 4.0 min vs. 10.0 min; p =0.008) was shorter in VSA group. The SOFA (5.0 vs. 9.0, p =0.007) and APACHE II score (20.5 vs. 25.0, p =0.007) at admission were lower in VSA group. The proportion of the patients who underwent coronary angiography (CAG) did not differ between the two groups and there were no patients with a newly diagnosed coronary obstructive lesion in CAG performed after ROSC. More patients in VSA group had good neurologic outcome at hospital discharge (77.8% vs. 47.3%, p =0.022), 28 days (76.5% vs. 48.4%, p =0.038), and 6 months (76.5% vs. 47.7%, p =0.037). All-cause mortality rate at in-hospital (5.6% vs. 42.1%, p =0.002) and 28 days (11.2% vs. 44.5%, p =0.009) were lower in VSA group. In the subgroup analysis of patients who underwent CAG, more patients with VSA showed lower mortality rate at in-hospital (0.0% vs. 35.4%, p =0.003) and 28 days (6.7% vs. 38.0%, p =0.019). Conclusion: In patients survived OHCA, patients with VSA more achieved pre-hospital ROSC and showed better neurologic outcome and lower mortality rate compared to those with other MI.

Prediction of neurological outcomes following the return of spontaneous circulation in patients with out-of-hospital cardiac arrest: Retrospective fast-and-frugal tree analysis

AimAlthough various quantitative methods have been developed for predicting neurological prognosis in patients with out-of-hospital cardiac arrest (OHCA), they are too complex for use in clinical practice. We aimed to develop a simple decision rule for predicting neurological outcomes following the return of spontaneous circulation (ROSC) in patients with OHCA using fast-and-frugal tree (FFT) analysis. MethodsWe performed a retrospective analysis of prospectively collected data archived in a multi-centre registry. Good neurological outcomes were defined as cerebral performance category (CPC) values of 1 or 2 at 28-day. Variables used for FFT analysis included age, sex, witnessed cardiac arrest, bystander cardiopulmonary resuscitation, initial shockable rhythm, prehospital defibrillation, prehospital ROSC, no flow time, low flow time, cause of arrest (cardiac or non-cardiac), pupillary light reflex, and Glasgow Coma Scale score after ROSC. ResultsAmong the 456 patients enrolled, 86 (18.9%) experienced good neurological outcomes. Prehospital ROSC (true = good), prompt or sluggish light reflex response after ROSC (true = good), and presumed cardiac cause (true = good, false = poor) were selected as nodes for the decision tree. Sensitivity, specificity, positive predictive value, and negative predictive value of the decision tree for predicting good neurological outcomes were 100% (42/42), 64.0% (119/186), 38.5% (42/109), and 100% (119/119) in the training set and 95.5% (42/44), 57.6% (106/184), 35.0% (42/120), and 98.1% (106/108) in the test set, respectively. ConclusionA simple decision rule developed via FFT analysis can aid clinicians in predicting neurological outcomes following ROSC in patients with OHCA.

Refractory out-of-hospital cardiac arrest with ongoing cardiopulmonary resuscitation at hospital arrival \u2013 survival and neurological outcome without extracorporeal cardiopulmonary resuscitation

BackgroundThe prognosis in refractory out-of-hospital cardiac arrest (OHCA) with ongoing cardiopulmonary resuscitation (CPR) at hospital arrival is often considered dismal. The use of extracorporeal cardiopulmonary resuscitation (eCPR) for perfusion enhancement during resuscitation has shown variable results. We aimed to investigate outcome in refractory OHCA patients managed conservatively without use of eCPR.MethodsWe included consecutive OHCA patients with refractory arrest or prehospital return of spontaneous circulation (ROSC) in the Copenhagen area in 2002–2011.ResultsA total of 3992 OHCA patients with resuscitation attempts were included; in 2599, treatment was terminated prehospital, and 1393 (35%) were brought to the hospital either with ROSC (n = 1285, 92%) or with refractory OHCA (n = 108, 8%). Of patients brought in with refractory OHCA, 56 (52%) achieved ROSC in the emergency department. There were no differences between patients with refractory OHCA or prehospital ROSC with regard to age, sex, comorbidities, or etiology of OHCA. Time to emergency medical services (EMS) arrival was similar, whereas time to ROSC (when ROSC was achieved) was longer in refractory OHCA patients (EMS, 6 (5–9] vs. 7 [5–10] min, p = 0.8; ROSC, 15 [9–22] vs. 27 [20–41] min, p < 0.001). Independent factors associated with transport with refractory OHCA instead of prehospital termination of therapy were OHCA in public (OR, 3.6 [95% CI, 2.2–5.8]; p < 0.001), witnessed OHCA (OR, 3.7 [2.0–7.1]; p < 0.001), shockable rhythm (OR, 3.0 [1.9–4.7]; p < 0.001), younger age (OR, 1.2 [1.1–1.2]; p < 0.001), and later calendar year (OR, 1.4 [1.2–1.6]; p < 0.001). Thirty-day survival was 20% in patients with refractory OHCA compared with 42% in patients with prehospital ROSC (p < 0.001). Four of 28 refractory OHCA patients with duration of resuscitation > 60 min achieved ROSC. No difference in favorable neurological outcome in patients surviving to discharge was found (prehospital ROSC 84% vs. refractory OHCA 86%; p = 0.7).ConclusionsSurvival after refractory OHCA with ongoing CPR at hospital arrival was significantly lower than among patients with prehospital ROSC. Despite a lower survival, the majority of survivors with both refractory OHCA and prehospital ROSC were discharged with a similar degree of favorable neurological outcome, indicating that continued efforts in spite of refractory OHCA are not in vain and may still lead to favorable outcome even without eCPR.

Blood gas analyses could not improve the termination of resuscitation criteria to predict subsequent recovery of spontaneous circulation in patients with out-of-hospital cardiac arrest: A diagnostic accuracy study

Background: The prehospital termination of resuscitation (TOR) rule including unwitnessed arrest, no shock administered, no prehospital return of spontaneous circulation (ROSC) parameters was widely accepted as a prediction model for survival to hospital discharge in patients with out-of-hospital cardiac arrest (OHCA). We hypothesized that blood gas analysis findings that can be achieved within minutes during resuscitation at emergency department (ED) in combination with conventional TOR criteria can improve prediction of ROSC in the ED.

Prognostic factors for survival and neurological outcomes in patients with prehospital ROSC

Prognostic factors for survival and neurological outcomes in patients with prehospital ROSC

Rhythm improvements from initial ECG rhythm before adrenaline administration influence prehospital ROSC in out-of-hospital cardiac arrest with non-shockable initial rhythm

Rhythm improvements from initial ECG rhythm before adrenaline administration influence prehospital ROSC in out-of-hospital cardiac arrest with non-shockable initial rhythm

Factors associated with outcomes in traumatic cardiac arrest patients without prehospital return of spontaneous circulation

BackgroundPrognostic factors for the outcomes in traumatic cardiac arrest (TCA) patients transported to hospitals without prehospital return of spontaneous circulation (ROSC) remain uncertain. The aim of this study is to investigate factors associated with outcomes in TCA patients without prehospital ROSC. MethodsWe conducted a retrospective cohort study using a multi-institutional, 5-year database. Only TCA patients without prehospital ROSC were included. The primary outcome was ROSC in the emergency department (ED), and the secondary outcome was 30-day survival. Logistic regression analysis was performed to determine the factors associated with primary and secondary outcomes. ResultsAmong 463 TCA patients, 73 (16%) had ROSC during ED resuscitation, and among those with sustained ROSC, 10 (14%) survived for at least 30 days. Injury severity score ≧ 16 (OR, 0.06; 95% CI: 0.02–0.20), trauma center admission (OR, 2.69; 95% CI: 1.03–7.03), length of ED resuscitation (OR, 0.98; 95% CI: 0.96-0.99), and total resuscitation length > 20 min (OR, 0.21; 95% CI: 0.08–0.54) were associated with ROSC. ConclusionsIn TCA patients transported to hospitals without prehospital ROSC, resuscitation attempts could be beneficial. We should aim to resuscitate patients as soon as possible with appropriate treatments for trauma patients, early activation of trauma team, and then, as a result, shorter resuscitation time will be achieved.

Effects of prehospital epinephrine administration on neurologically intact survival in bystander-witnessed out-of-hospital cardiac arrest patients with non-shockable rhythm depend on prehospital cardiopulmonary resuscitation duration required to hospital arrival.

The effects of prehospital epinephrine administration on post-arrest neurological outcome in out-of-hospital cardiac arrest (OHCA) patients with non-shockable rhythm remain unclear. To examine the time-dependent effectiveness of prehospital epinephrine administration, we analyzed 118,396 bystander-witnessed OHCA patients with non-shockable rhythm from the prospectively recorded all-Japan OHCA registry between 2011 and 2014. Patients who achieved prehospital return of spontaneous circulation without prehospital epinephrine administration were excluded. Patients with prehospital epinephrine administration were stratified according to the time from the initiation of cardiopulmonary resuscitation (CPR) by emergency medical service (EMS) providers to the first epinephrine administration (≤ 10, 11-19, and ≥ 20min). Patients without prehospital epinephrine administration were stratified according to the time from CPR initiation by EMS providers to hospital arrival (≤ 10, 11-19, and ≥ 20min). The primary outcome was 1-month neurologically intact survival (cerebral performance category 1 or 2; CPC 1-2). Multivariate logistic regression analysis demonstrated that there was no significant difference in the chance of 1-month CPC 1-2 between patients who arrived at hospital in ≤ 10min without prehospital epinephrine administration and patients with time to epinephrine administration ≤ 19min. However, compared to patients who arrived at hospital in ≤ 10min without prehospital epinephrine administration, patients with time to epinephrine administration ≥ 20min and patients who arrived at hospital in 11-19, and ≥ 20min without prehospital epinephrine administration were significantly associated with decreased chance of 1-month CPC 1-2 (p < 0.05, < 0.05, and < 0.001, respectively). In conclusion, when prehospital CPR duration from CPR initiation by EMS providers to hospital arrival estimated to be ≥ 11min, prehospital epinephrine administered ≤ 19min from CPR initiation by EMS providers could improve neurologically intact survival in bystander-witnessed OHCA patients with non-shockable rhythm.

Effects of intra-resuscitation antiarrhythmic administration on rearrest occurrence and intra-resuscitation ECG characteristics in the ROC ALPS trial

BackgroundIntra-resuscitation antiarrhythmic drugs may improve resuscitation outcomes, in part by avoiding rearrest, a condition associated with poor out-of-hospital cardiac arrest (OHCA) outcomes. However, antiarrhythmics may also alter defibrillation threshold. The objective of this study was to investigate the relationship between rearrest and intra-resuscitation antiarrhythmic drugs in the context of the Resuscitation Outcomes Consortium (ROC) amiodarone, lidocaine, and placebo (ALPS) trial. HypothesisRearrest rates would be lower in cases treated with amiodarone or lidocaine, versus saline placebo, prior to first return of spontaneous circulation (ROSC). We also hypothesized antiarrhythmic effects would be quantifiable through analysis of the prehospital electrocardiogram. MethodsWe conducted a secondary analysis of the ROC ALPS trial. Cases that first achieved prehospital ROSC after randomized administration of study drug were included in the analysis. Rearrest, defined as loss of pulses following ROSC, was ascertained from emergency medical services records. Rearrest rate was calculated overall, as well as by ALPS treatment group. Multivariable logistic regression models were constructed to assess the association between treatment group and rearrest, as well as rearrest and both survival to hospital discharge and survival with neurologic function. Amplitude spectrum area, median slope, and centroid frequency of the ventricular fibrillation (VF) ECG were calculated and compared across treatment groups. ResultsA total of 1144 (40.4%) cases with study drug prior to first ROSC were included. Rearrest rate was 44.0% overall; 42.9% for placebo, 45.7% for lidocaine, and 43.0% for amiodarone. In multivariable logistic regression models, ALPS treatment group was not associated with rearrest, though rearrest was associated with poor survival and neurologic outcomes. AMSA and median slope measures of the first available VF were associated with rearrest case status, while median slope and centroid frequency were associated with ALPS treatment group. ConclusionRearrest rates did not differ between antiarrhythmic and placebo treatment groups. ECG waveform characteristics were correlated with treatment group and rearrest. Rearrest was inversely associated with survival and neurologic outcomes.

LO03: Impact of the conversion to a shockable rhythm from a non-shockable rhythm for patients suffering from out-of-hospital cardiac arrest

Introduction: Patients suffering from out-of-hospital cardiac arrest (OHCA) with an initial shockable rhythm (ventricular tachycardia or ventricular fibrillation) have higher odds of survival than those suffering from non-shockable rhythm (asystole or pulseless electrical activity). Because of that prognostic significance, patients with an initial non-shockable rhythm are often not considered for advanced resuscitation therapies such as extracorporeal resuscitation. However, the prognostic significance of the conversion to a shockable rhythm from an initially non-shockable rhythm remains uncertain. This study aimed to determine the degree of association between the conversion (or not) of a non-shockable rhythm to a shockable rhythm and resuscitation outcomes in patients with OHCA. It was hypothesized that such a conversion would be associated with a higher survival to discharge. Methods: The present study used a registry of adult OHCA between 2010 and 2015 in Montreal, Canada. Adult patients with non-traumatic OHCA and an initial non-shockable rhythm were included. The primary outcome measure was survival to hospital discharge, and the secondary outcome measure was prehospital return of spontaneous circulation (ROSC). The associations of interest were evaluated with univariate logistic regressions and multivariate models controlling for demographic and clinical variables (e.g. age, gender, type of initial non-shockable rhythm, witnessed arrest, bystander cardiopulmonary resuscitation). Assuming a survival rate of 3% and 25% of the variability explained by the control variables, including more than 4580 patients would allow to detect an absolute difference of 4% in survival between both groups with a power of more than 90%. Results: A total of 4893 patients (2869 men and 2024 women) with a mean age of 70 years (standard deviation 17) were included, of whom 450 (9.2%) experienced a conversion to a shockable rhythm during the course of their prehospital resuscitation. Among all patients, 146 patients (3.0%) survived to discharge and 633 (12.9%) experienced prehospital ROSC. In the univariate models, there was no association between the conversion to a shockable rhythm and survival (odds ratio [OR] 1.14 [95% confidence interval {CI} 0.66-1.95]), but a significant assocation was observed with ROSC (OR 2.00 [95% CI 1.57-2.55], p&lt;0.001). However, there was no independent association between the conversion to a shockable rhythm and survival (adjusted OR [AOR] 0.92 [95% CI 0.51-1.66], p=0.78) and prehospital ROSC (AOR 1.30 [95% CI 0.98-1.72], p=0.073). Conclusion: There is no clinically significant association between the conversion to a shockable rhythm and resuscitation outcomes in patients suffering from OHCA. The initial rhythm remains a much better outcome predictor than subsequent rhythms and should be preferred when evaluating the eligibility for advanced resuscitation procedures.

P029: A descriptive analysis of defibrillation vector change for prehospital refractory ventricular fibrillation

Introduction: Patients in ventricular fibrillation (VF) who do not respond to standard Advanced Cardiac Life Support treatments are deemed to be in refractory VF (rVF). The ideal prehospital treatment for patients with rVF remains unknown. Double sequential external defibrillation (DSED) has been proposed as a viable option for patients in rVF. Although the mechanism by which DSED terminates rVF remains unknown, one theory is that the change in defibrillation vector that occurs may contribute. The objective of this study was to describe clinical outcomes for patients presenting in rVF during out-of-hospital cardiac arrest (OOHCA) for those who underwent vector change defibrillation, compared to those who received standard treatment. Methods: This was a retrospective chart review of adult (18 years) patients presenting in rVF during OOHCA over 15 months beginning in March 2016. Patients who underwent vector change defibrillation had a change in pad position (anterior-anterior to anterior-posterior) after 3 or more consecutive shocks. Termination of rVF was defined as the absence of VF after a vector change or standard shock during the next rhythm analysis. Results: There were 372 OOHCA, with 25 (6.7%) patients meeting our definition of rVF. Of these, 16 (64.0%) patients (median age 62 years, 81.3% male) had vector change after a median (IQR) of 3 (3.0-4.0) paramedic defibrillation attempts. Median (IQR) time to vector change defibrillation was 8.8 (7.1-11.1) minutes. Eight (50%) patients had termination of rVF after the first vector change shock, 6 (37.5%) had prehospital return of spontaneous circulation (ROSC) and 5 (31.3%) patients survived to hospital discharge. Of the 9 rVF patients who did not have vector change, median age was 63 years and 88.9% were male. The median (IQR) number of defibrillations within this group was 5 (4.5-7.0). No patients converted after the 4th defibrillation. Prehospital ROSC was achieved in 3 (33.3%) patients and 5 (55.5%) patients were transported while in rVF . Three patients (33.3%) survived to hospital discharge. Conclusion: This is preliminary evidence that vector change defibrillation in patients with rVF may result in VF termination. A randomized controlled trial is warranted to test whether or not vector change has a role in the termination of rVF.

Association of Prehospital Advanced Life Support by Physician With Survival After Out-of-Hospital Cardiac Arrest With Blunt Trauma Following Traffic Collisions

Controversy remains as to whether advanced life support (ALS) or basic life support (BLS) is superior for critically ill and injured patients, including out-of-hospital cardiac arrest (OHCA) and major trauma, in the prehospital setting. To assess whether prehospital ALS should be provided for traumatic OHCA and who should perform it. Japanese government-managed nationwide population-based registry data of patients with OHCA transported to an emergency hospital were analyzed. Patients who experienced traumatic OHCA following a traffic collision from 2013 to 2014 were included. Patients provided prehospital ALS by a physician were compared with both patients provided ALS by emergency medical service (EMS) personnel and patients with only BLS. The data were analyzed on May 1, 2017. Advanced life support by physician, ALS by EMS personnel, or BLS only. The primary outcome was 1-month survival. The secondary outcomes were prehospital return of spontaneous circulation and favorable neurologic outcomes with the Glasgow-Pittsburgh cerebral performance category score of 1 or 2. A total of 4382 patients were included (mean [SD] age, 57.5 [22.2] years; 67.9% male); 828 (18.9%) received prehospital ALS by physician, 1591 (36.3%) received prehospital ALS by EMS personnel, and 1963 (44.8%) received BLS only. Among these patients, 96 (2.2%) survived 1 month after OHCA, including 26 of 828 (3.1%) for ALS by physician, 25 of 1591 (1.6%) for ALS by EMS personnel, and 45 of 1963 (2.3%) for BLS. After adjusting for potential confounders using multivariable logistic regression, ALS by physician was significantly associated with higher odds for 1-month survival compared with both ALS by EMS personnel and BLS (adjusted OR, 2.13; 95% CI, 1.20-3.78; and adjusted OR, 1.94; 95% CI, 1.14-3.25; respectively), whereas there was no significant difference between ALS by EMS personnel and BLS (adjusted OR, 0.91; 95% CI, 0.54-1.51). A propensity score-matched analysis in the ALS cohort showed that ALS by physician was associated with increased chance of 1-month survival compared with ALS by EMS personnel (risk ratio, 2.00; 95% CI, 1.01-3.97; P = .04). This association was consistent across a variety of sensitivity analyses. In traumatic OHCA, ALS by physician was associated with increased chance of 1-month survival compared with both ALS by EMS personnel and BLS.

Abstract MP73: Emergency Call First Strategy versus Bystander Cardiopulmonary Resuscitation First Strategy for Out-of-Hospital Cardiac Arrest

Introduction: Lay rescuers have a crucial role in successful cardiopulmonary resuscitation (CPR), specifically the first three links in the chain of survival, for out-of-hospital cardiac arrest (OHCA). However, randomized controlled trials on the priority of emergency call (Call first) versus bystander CPR (CPR first) do not exist, and comparative data are very limited. We aimed to assess the association between the priority of bystander’s action (Call first vs. CPR first) and neurologic outcome after OHCA. Methods: This nationwide population-based study of patients who experienced OHCA from January 2005 to December 2014 was based on the data from the Japanese government-managed registry of OHCA. Patients provided bystander’s action (both emergency call and bystander CPR) within 1 minute of witness were included, and Call first strategy was compared with CPR first strategy. The primary outcome was one-month neurologically favorable survival, defined as a Glasgow-Pittsburgh cerebral performance category (CPC) score of 1(good performance) or 2(moderate disability). The secondary outcomes were prehospital return of spontaneous circulation (ROSC) and one-month overall survival. Results: A total of 25,840 patients were included; 4,430 (17.1%) were treated with Call first approach, and 21,410 (82.9%) were treated with CPR first approach. Among total cohort, 2,696 (10.4%) survived with neurologically favorable status one month after OHCA. In the propensity score-matched cohort, one-month neurologically favorable survival was lower among Call first group compared with CPR first group: 364 of 4,430 patients (8.2%) vs. 457 of 4,430 patients (10.3%), respectively (Risk ratio [RR], 0.80; 95% confidence interval [CI], 0.70-0.91). Similar associations were observed for one-month overall survival (RR, 0.90; 95%CI, 0.82-0.99), although there were no significant differences in prehospital ROSC (RR, 0.94; 95%CI, 0.86-1.02) between the Call first and CPR first groups. In subgroup analyses, the association between delayed bystander CPR and worse neurological outcome did not change regardless of subgroup characteristics. Conclusions: In witnessed OHCA, Call first approach was associated with a decreased chance of one-month neurologically favorable survival compared with CPR first approach. These observational findings warrant a randomized clinical trial to determine the priority of emergency call or bystander CPR for OHCA.

Out-of-Hospital Cardiac Arrest in the Pediatric Population in Hong Kong: A 10-Year Review at a University Hospital.

To describe the epidemiology and outcomes of out-of-hospital cardiac arrest (OHCA) in a Hong Kong (HK) pediatric population and to identify factors associated with favorable outcomes. Retrospective case note review of patients younger than 18 years who presented to the emergency department of Prince of Wales Hospital, HK with cardiac arrest from 2003 to 2013. Patients were classified as infants (<1 year), children (1-11 years) and adolescents (12-18 years). Patient characteristics, OHCA details, interventions, and outcomes were reported following the Utstein format. There were 53 patients in the study (77.4% men) and 34.6% of patients had chronic illnesses. In the infant group, 35.7% had complicated pregnancies. The incidence of OHCA in HK was 5.37 per 100,000 person-years. Out-of-hospital cardiac arrest was identified by bystanders in 62.3%, but bystander cardiopulmonary resuscitation was provided in only 28.3%. Shockable rhythms were uncommon (9.4%). Most OHCA in infants had unknown causes. In children, commonest causes were respiratory illness and environmental hazards, and in adolescents, trauma and cardiogenic events. Overall survival to hospital discharge rate was 20.8%; 13.2% had good neurological outcomes. Bystander cardiopulmonary resuscitation (odds ratio [OR], 7.44; 95% confidence interval [95% CI], 1.75-31.7; P = 0.007), prehospital return of spontaneous circulation (OR, 11.4; 95% CI, 1.75-74.7; P = 0.013), and return of spontaneous circulation within 30 minutes (OR, 90.0; 95% CI, 11.1-727; P < 0.0005) were associated with survival to discharge. The incidence of OHCA in HK is comparable to global data. The outcome of OHCA in the pediatric population has improved over the decades. Better prehospital care could improve outcome.

Duration of cardiopulmonary resuscitation in patients without prehospital return of spontaneous circulation after out-of-hospital cardiac arrest: Results from a severity stratification analysis

BackgroundThe relationship between duration of cardiopulmonary resuscitation (CPR) and post-arrest outcomes based on severity stratification in out-of-hospital cardiac arrest (OHCA) patients without prehospital return of spontaneous circulation (ROSC) remains unclear. MethodsWe analysed 420,959 adult patients without prehospital ROSC in the All-Japan OHCA registry for 4 years. Prehospital CPR duration was defined as the time from CPR initiation by emergency medical service (EMS) providers to hospital arrival. The primary outcome was 1-month neurologically intact survival (cerebral performance category 1 or 2, CPC 1–2). ResultsThe rate of overall 1-month CPC 1–2 was 0.45% (1899/420,959). Using recursive partitioning analysis to predict 1-month CPC 1–2, we stratified patients into 4 groups with 3 predictors: patients aged <75 years with initial shockable rhythm (1-month CPC 1–2 rate, 6.15%), those aged ≥75 years with initial shockable rhythm (1.32%), those with EMS-witnessed arrest and initial non-shockable rhythm (1.62%), and those with EMS-unwitnessed arrest and initial non-shockable rhythm (0.15%). Prehospital CPR duration was negatively associated with 1-month CPC 1–2 (adjusted odds ratio 0.94 per 1-min increment; 95% confidence interval 0.94–0.95). Prehospital CPR durations beyond which the dynamic probability of 1-month CPC 1–2 decreased to <1% were 26 min, 10 min, 7 min, and at all times in above-mentioned stratification, respectively. ConclusionsIn OHCA patients without prehospital ROSC, those aged <75 years with initial shockable rhythm had acceptable 1-month CPC 1–2 rate. However, CPR efforts lasting 26 min or over before hospital arrival could be futile.

Resuscitation of Out-of-Hospital Cardiac Arrest Victims in Lebanon: The Experience and Views of Prehospital Providers.

Background:The survival rate of out-of-hospital cardiac arrest (OHCA) victims in Lebanon is much lower than those seen internationally. In this study, we examined the attitudes and practices of prehospital providers in resuscitation.Methods:We devised a cross-sectional survey with questions adopted from the literature including a study out of Lebanon. Questionnaires were mailed to 300 volunteers who were recruited from 10 centers of local emergency medical services (EMS).Results:A total of 258 questionnaires were returned (86% response rate). Most participants (>80%) were younger than 30 years, and males (60%). Over half reported witnessing up to 10 arrests per year, with 72.5% reporting prehospital return of spontaneous circulation in <6% of cases. Futile resuscitation was frequently (91%) practiced. Participants believed resuscitation should be withdrawn when prolonged (55.4%) or in the presence of advanced directives (34.1%) or terminal illness (27.5%). Reported resuscitation challenges were related to the reaction of witnesses (70.1%), to delay in calling EMS (84.4%), and to traffic delays (30%). Participants recommended training lay persons in resuscitation (79%), training prehospital providers in advanced airway management (68.2%) and intravenous skills (60.1%), providing medications in ambulances (57.7%), and adjusting traffic laws (52%).Conclusion:Prehospital providers in Lebanon face several challenges in their resuscitation practices. A multi-faceted strategy to improve resuscitation practices is needed in Lebanon. In addition to policy development, structural changes should be put in place for improved outcomes in OHCA victims.

Initial blood pH during cardiopulmonary resuscitation in out-of-hospital cardiac arrest patients: a multicenter observational registry-based study

BackgroundWhen an out-of-hospital cardiac arrest (OHCA) patient receives cardiopulmonary resuscitation (CPR) in the emergency department (ED), blood laboratory test results can be obtained by using point-of-care testing during CPR. In the present study, the relationship between blood laboratory test results during CPR and outcomes of OHCA patients was investigated.MethodsThis study was a multicenter retrospective analysis of prospective registered data that included 2716 OHCA patients. Data from the EDs of three university hospitals in different areas were collected from January 2009 to December 2014. Univariate and multivariable analyses were conducted to elucidate the factors associated with survival to discharge and neurological outcomes. A final analysis was conducted by including patients who had no prehospital return of spontaneous circulation and those who underwent rapid blood laboratory examination during CPR.ResultsOverall, 2229 OHCA patients were included in the final analysis. Among them, the rate of survival to discharge and a good Cerebral Performance Categories Scale score were 14% and 4.4%, respectively. The pH level was independently related to survival to hospital discharge (adjusted OR 6.287, 95% CI 2.601–15.197; p < 0.001) and good neurological recovery (adjusted OR 15.395, 95% CI 3.439–68.911; p < 0.001). None of the neurologically intact patients had low pH levels (< 6.8) or excessive potassium levels (> 8.5 mEq/L) during CPR.ConclusionsAmong the blood laboratory test results during CPR of OHCA patients, pH and potassium levels were observed as independent factors associated with survival to hospital discharge, and pH level was considered as an independent factor related to neurological recovery.

An assessment of ventilation and perfusion markers in out-of-hospital cardiac arrest patients receiving mechanical CPR with endotracheal or supraglottic airways

Aim of the studyMechanical chest compression (MCPR) devices are considered equivalent to manual compressions in patient outcomes in out-of-hospital cardiac arrest (OHCA). However, recent data suggest possible harm in patients with a supraglottic airway device (SGA) during MCPR. The aim of this study was to evaluate differences in direct and indirect markers of ventilation and perfusion in patients with cardiac arrest receiving MCPR and who had their airway managed with an endotracheal tube (ETT) or SGA. MethodsWe retrospectively reviewed Emergency Medical Services (EMS) agencies and emergency department (ED) records over a two-year period. We included patients with OHCA who underwent MCPR and who had an advanced airway placed. The primary outcome was differences in intra-arrest end-tidal carbon dioxide (etCO2) measurements. Secondary outcomes included intra-arrest ventilation rates, rates of prehospital return of spontaneous circulation (ROSC), blood pressure upon prehospital ROSC, and 24-h survival. ResultsValid data sets were available for 126 patients. Eighty-four (66.7%) had an ETT placed, and 42 (33.3%) had a SGA placed. Twenty-eight (22.6%) achieved prehospital ROSC. Twenty-four-hour survival data were available for 13 (10.3%) of these patients. There were no significant differences in primary or secondary outcomes. ConclusionIn this retrospective study, we found no evidence of differences in markers of ventilation, perfusion or prehospital ROSC and survival in patients with OHCA who had their airway managed with either an ETT or SGA while receiving MCPR.

Association of the Emergency Medical Services–Related Time Interval with Survival Outcomes of Out-of-Hospital Cardiac Arrest Cases in Four Asian Metropolitan Cities Using the Scoop-and-Run Emergency Medical Services Model

BackgroundResponse time interval (RTI) and scene time interval (STI) are key time variables in the out-of-hospital cardiac arrest (OHCA) cases treated and transported via emergency medical services (EMS). ObjectiveWe evaluated distribution and interactive association of RTI and STI with survival outcomes of OHCA in four Asian metropolitan cities. MethodsAn OHCA cohort from Pan-Asian Resuscitation Outcome Study (PAROS) conducted between January 2009 and December 2011 was analyzed. Adult EMS-treated cardiac arrests with presumed cardiac origin were included. A multivariable logistic regression model with an interaction term was used to evaluate the effect of STI according to different RTI categories on survival outcomes. Risk-adjusted predicted rates of survival outcomes were calculated and compared with observed rate. ResultsA total of 16,974 OHCA cases were analyzed after serial exclusion. Median RTI was 6.0 min (interquartile range [IQR] 5.0–8.0 min) and median STI was 12.0 min (IQR 8.0-16.1). The prolonged STI in the longest RTI group was associated with a lower rate of survival to discharge or of survival 30 days after arrest (adjusted odds ratio [aOR] 0.59; 95% confidence interval [CI] 0.42–0.81), as well as a poorer neurologic outcome (aOR 0.63; 95% CI 0.41–0.97) without an increasing chance of prehospital return of spontaneous circulation (aOR 1.12; 95% CI 0.88–1.45). ConclusionsProlonged STI in OHCA with a delayed response time had a negative association with survival outcomes in four Asian metropolitan cities using the scoop-and-run EMS model. Establishing an optimal STI based on the response time could be considered.