Prehospital cardiac arrest: The impact of witnessed collapse and bystander CPR in a metropolitan EMS system with short response times

doi:10.1016/S0196-0644(05)82285-1

Annals of Emergency Medicine

Volume 19, Issue 11, November 1990, Pages 1264-1269

https://doi.org/10.1016/S0196-0644(05)82285-1 Get rights and content

Objective:

Numerous studies have shown initiation of bystander CPR to significantly improve survival from prehospital cardiac arrest. However, in emergency medical services (EMS) systems with very short response times, bystander CPR has not been shown to impact outcome. The purpose of this study was to determine the effect of bystander CPR on survival from out-of-hospital cardiac arrest in such a system.

Design:

Prehospital, hospital, and death certificate data from a medium-sized metropolitan area were retrospectively analyzed for adult, nontraumatic cardiac arrest during a 16-month period.

Results:

A total of 298 patients met study criteria. One hundred ninety-five arrests (65.4%) were witnessed, and 103 (34.6%) were unwitnessed. Twenty-five witnessed victims (12.8%) were discharged alive, whereas no unwitnessed victims survived (P < .001). Patients suffering a witnessed episode of ventricular fibrillation/tachycardia (VF/VT) were more likely to survive (21.9%) than were other patients (2.0%, P < .0001). Among witnessed patients, initiation of bystander CPR was associated with a significant improvement in survival (20.0%) compared with the no-bystander CPR group (9.2%, P < .05). Bystander CPR was also associated with improved outcome when witnessed patients with successful prehospital resuscitation were evaluated as a group; 18 had bystander CPR, of whom 13 (72.2%) survived compared with only 12 of 38 patients with no bystander CPR (31.6%, P < .01).

Conclusion:

Our data revealed improved survival rates when bystander CPR was initiated on victims of witnessed cardiac arrest in an EMS system with short response times.

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The Girona Territori Cardioprotegit Project: Performance Evaluation of Public Defibrillators
2018, Revista Espanola de Cardiologia
La desfibrilación pública ha potenciado la difusión y el uso de los desfibriladores externos automáticos (DEA) de manera exponencial, pero se carece de datos recientes sobre su uso en nuestro medio. Se realizó un análisis descriptivo del funcionamiento de los DEA desde el despliegue de un programa de desfibrilación pública.
Análisis retrospectivo de los trazados electrocardiográficos registrados y del funcionamiento de los desfibriladores, en el marco de un programa de desfibrilación pública en la provincia de Girona, desde su inicio en junio de 2011 hasta junio de 2015.
De 231 activaciones, se dispuso de información completa en 188, entre dispositivos móviles (82%) y fijos (18%). La asistolia fue el ritmo más prevalente (42%), mientras que un 23% de los ritmos fueron fibrilación ventricular. La especificidad de los dispositivos identificando ritmos desfibrilables fue del 100%, pero hubo 8 falsos negativos (sensibilidad del 83%). En el caso de los 47 ritmos desfibrilables, la tasa de recuperación de la circulación espontánea fue del 49% (23 casos). No hubo ningún accidente relacionado con el uso del dispositivo.
Casi la mitad de los ritmos registrados fueron asistolias. Los DEA analizados presentaron excelentes seguridad y especificidad, con una sensibilidad moderada. El DEA trató con éxito a la mitad de los pacientes que presentaron ritmo desfibrilable.
In recent years, public access defibrillation programs have exponentially increased the availability of automatic external defibrillators (AED) in public spaces but there are no data on their performance in our setting. We conducted a descriptive analysis of the performance of AED since the launch of a public defibrillation program in our region.
A retrospective analysis was conducted of electrocardiographic tracings and the performance of AED in a public defibrillation program from June 2011 to June 2015 in the province of Girona, Spain.
There were 231 AED activations. Full information was available on 188 activations, of which 82% corresponded to mobile devices and 18% to permanent devices. Asystole was the most prevalent rhythm (42%), while ventricular fibrillation accounted for 23%. The specificity of the device in identifying a shockable rhythm was 100%, but there were 8 false negatives (sensitivity 83%). There were 47 shockable rhythms, with a spontaneous circulation recovery rate of 49% (23 cases). There were no accidents related to the use of the device.
Nearly half of the recorded rhythms were asystole. The AED analyzed showed excellent safety and specificity, with moderate sensitivity. Half the patients with a shockable rhythm were successfully treated by the AED.
Full English text available from: www.revespcardiol.org/en
The duration of cardiopulmonary resuscitation in emergency departments after out-of-hospital cardiac arrest is associated with the outcome: A nationwide observational study
2015, Resuscitation
The appropriate duration of cardiopulmonary resuscitation (CPR) for patients who experience out-of-hospital cardiac arrest (OHCA) remains unknown. This study aimed to evaluate the duration of CPR in emergency departments (EDs) and to determine whether the institutions’ median duration of CPR was associated with survival-to-discharge rate.
A cohort of adult patients from a nationwide OHCA registry was retrospectively evaluated. The main variable was the median duration of CPR for each ED (institutional duration), and the main outcome was survival to discharge. Multivariable logistic regression analysis was performed to adjust for individual and aggregated confounders.
Among the 107,736 patients who experienced OHCA between 2006 and 2010, 30,716 (28.5%) were selected for analysis. The median age was 65 years, and 67.1% were men. The median duration of CPR for all EDs was 28 min, ranging from 11 to 45 min. EDs were categorized into 3 groups according to their institutional duration of CPR: groups A (<20 min), B (20–29 min), C (≥30 min). The observed survival rates of the 3 groups were 2.11%, 5.20%, and 5.62%, respectively. Compared with group B, the adjusted difference (95% confidence interval) for survival to discharge was 3.01% (1.90–4.11, P < 0.001) for group A, and 0.33% (−0.64 to 1.30, P = 0.51) for group C.
The duration of CPR varied widely among hospitals. The institutional duration of CPR less than 20 min was significantly associated with lower survival-to-discharge rate.
The effect of mild therapeutic hypothermia on good neurological recovery after out-of-hospital cardiac arrest according to location of return of spontaneous circulation: A nationwide observational study
2015, Resuscitation
Mild therapeutic hypothermia (MTH) has been known to be associated with good neurological recovery after out-of-hospital cardiac arrest (OHCA). Prehospital return of spontaneous circulation (P-ROSC) is associated with better hospital outcomes than ROSC at emergency department (ED-ROSC). The study aims to examine the association between MTH by location of ROSC and good neurological recovery after OHCA.
Adult OHCA cases with presumed cardiac etiology who survived to hospital admission were collected from a nationwide cardiac registry between 2008 and 2013. MTH was defined as a case receiving hypothermia procedure regardless of procedure method. Primary outcome was good neurological recovery with cerebral performance category score of 1 and 2. Multivariable logistic regression analysis was performed adjusting for potential confounders with an interaction term between MTH and location of ROSC to calculate adjusted odds ratios (AORs) and 95% confidence intervals (CIs).
Among 11,158 patients survived to admission, good neurological recovery was 23.6% (399/1691) in MTH vs. 15.0% (1400/9316) in non-MTH (p < 0.001), and 58.2% (1074/1864) in P-ROSC vs. 7.9% (725/9161) in ED-ROSC (p < 0.001). There was a significant association between MTH and good neurological recovery (AOR = 1.32, 95% CI = 1.11–1.57). In the interaction model, AOR of MTH and interaction effect with P-ROSC and ED-ROSC was 0.78 (0.58–2.70) and 1.68 (1.34–1.98), respectively.
MTH was significantly associated with good neurological recovery among OHCA survivors. In the interaction model, MTH showed significant benefits in patient group with ROSC at ED, not in P-ROSC group.
Statewide regionalization of postarrest care for out-of-hospital cardiac arrest: Association with survival and neurologic outcome
2014, Annals of Emergency Medicine
Citation Excerpt :
If the results can be replicated, communities should consider out-of-hospital cardiac arrest care regionalization strategies. For decades, out-of-hospital cardiac arrest has been a major focus of emergency medical services (EMS) systems, and several bystander and EMS interventions have been shown to improve outcomes.1-10 In contrast, inhospital postarrest care of out-of-hospital cardiac arrest has historically received little attention.
For out-of-hospital cardiac arrest, authoritative, evidence-based recommendations have been made for regionalization of postarrest care. However, system-wide implementation of these guidelines has not been evaluated. Our hypothesis is that statewide regionalization of postarrest interventions, combined with emergency medical services (EMS) triage bypass, is associated with improved survival and neurologic outcome.
This was a prospective before-after observational study comparing patients admitted to cardiac receiving centers before implementation of the interventions (“before”) versus those admitted after (“after”). In December 2007, the Arizona Department of Health Services began officially recognizing cardiac receiving centers according to commitment to provide specified postarrest care. Subsequently, the State EMS Council approved protocols allowing preferential EMS transport to these centers. Participants were adults (≥18 years) experiencing out-of-hospital cardiac arrest of presumed cardiac cause who were transported to a cardiac receiving center. Interventions included (1) implementation of postarrest care at cardiac receiving centers focusing on provision of therapeutic hypothermia and coronary angiography or percutaneous coronary interventions (catheterization/PCI); and (2) implementation of EMS bypass triage protocols. Main outcomes included discharged alive from the hospital and cerebral performance category score at discharge.
During the study (December 1, 2007, to December 31, 2010), 31 hospitals were recognized as cardiac receiving centers statewide. Four hundred forty patients were transported to cardiac receiving centers before and 1,737 after. Provision of therapeutic hypothermia among patients with return of spontaneous circulation increased from 0% (before: 0/145; 95% confidence interval [CI] 0% to 2.5%) to 44.0% (after: 300/682; 95% CI 40.2, 47.8). The post return of spontaneous circulation catheterization PCI rate increased from 11.7% (17/145; 95% CI 7.0, 18.1) before to 30.7% (210/684; 95% CI 27.3, 34.3) after. All-rhythm survival increased from 8.9% (39/440) to 14.4% (250/1,734; adjusted odds ratio [aOR]=2.22; 95% CI 1.47 to 3.34). Survival with favorable neurologic outcome (cerebral performance category score=1 or 2) increased from 5.9% (26/439) to 8.9% (153/1,727; aOR=2.26 [95% CI 1.37, 3.73]). For witnessed shockable rhythms, survival increased from 21.4% (21/98) to 39.2% (115/293; aOR=2.96 [95% CI 1.63, 5.38]) and cerebral performance category score=1 or 2 increased from 19.4% (19/98) to 29.8% (87/292; aOR=2.12 [95% CI 1.14, 3.93]).
Implementation of a statewide system of cardiac receiving centers and EMS bypass was independently associated with increased overall survival and favorable neurologic outcome. In addition, these outcomes improved among patients with witnessed shockable rhythms.
Association between resuscitation time interval at the scene and neurological outcome after out-of-hospital cardiac arrest in two asian cities
2014, Resuscitation
It is unclear whether the scene time interval (STI) for cardiopulmonary resuscitation (CPR) is associated with outcomes of out-of-hospital cardiac arrest (OHCA) or not. The present study aimed to determine the association between STI and neurological outcome after OHCA using two large population-based cohorts covering two metropolitan cities in Asia.
A retrospective analysis based on two large population-based cohorts from Seoul (2008–2010) and Osaka (2007–2009) was performed for witnessed adult OHCA with presumed cardiac aetiology. The STI, defined as time from wheel arrival at the scene to departure to hospital, was categorised as short (<8 min), intermediate (from 8 to <16 min) and long (16 min or longer) STI on the basis of sensitivity analysis. The primary outcome was good neurological outcome (cerebral performance category 1 or 2). Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were calculated to determine the association between STIs and outcomes in comparison to the short STI group adjusting for potential risk factors and interaction products.
A total of 7757 patients, 3594 from Seoul and 4163 from Osaka, were finally analysed. There were significant differences among the STI groups for most potential risk variables. Survival to admission was higher in the intermediate STI group (35.7%) than in the short (31.8%) or long STI group (32.6%) (p = 0.004). Survival to discharge was not different among groups, at 13.7%, 13.1% and 11.5%, respectively (p = 0.094). The intermediate STI group had a significantly better neurological outcome compared with the short STI group (7.7% vs. 4.6%; AOR = 1.32; 95% CI, 1.03–1.71), while the long STI (6.6%) did not.
Data from two metropolitan cities demonstrated a positive association between intermediate STI from 8 to 16 min and good neurological outcome after OHCA.
Analysis of care in cardiorespiratory arrest in an emergency medical unit
2011, Atencion Primaria
Describir el perfil epidemiológico de las paradas cardiorrespiratorias (PCR) y determinar los factores asociados al éxito de las maniobras de reanimación cardiopulmonar (RCP).
Estudio observacional descriptivo retrospectivo.
Ciudad de Badajoz y población atendida por una Unidad Medicalizada de Emergencias (UME) del Sistema Público de Salud de dicha ciudad.
Se estudian 359 PCR reanimadas entre enero de 2002 y mayo de 2009.
De las PCR ocurridas en adultos, el 65,4% eran varones, el 65,7% tuvieron lugar en el domicilio, en el 88% la causa fue no traumática, y en el 6% se habían realizado maniobras de RCP básica previas a la llegada de la unidad medicalizada. El porcentaje mayor de éxito se consiguió en los pacientes varones (OR: 0,43; IC 95%: 0,25-0,73; p = 0,002), cuando el ritmo fue desfibrilable (OR: 0,16; IC 95%: 0,09-0,27; p < 0,001) y cuando el inicio de maniobras de soporte vital avanzado (SVA) fue igual o inferior a 10 minutos (OR: 0,22; IC 95%: 0,10-0,49; p < 0,001). En el análisis multivariante, el éxito se asoció de forma independiente al sexo masculino, ritmo inicial desfibrilable y tiempo de inicio de las maniobras de SVA igual o inferior a 10 minutos. Se reanimaron 9 niños, pero no se consiguió éxito en ninguno de ellos.
Las PCR predominan en los adultos, y en pocos casos se realiza RCP previa a la llegada de la unidad de emergencias. El sexo masculino, un ritmo eléctrico desfibrilable y el inicio precoz de las maniobras de SVA, se asocian a un mayor éxito. Es escaso el número de PCR asistidas en niños y el pronóstico más desfavorable.
To describe the epidemiological profile of cardiac arrests and to determine factors associated with successful cardiopulmonary resuscitation (CPR).
Retrospective descriptive observational study.
Badajoz city (Spain) and population attended by the Medical Emergency Unit of the Public Health System in that city.
A study 359 cardiac arrests resuscitated between January 2002 and May 2009.
Out of the cardiac arrests that ocurred in adults, 65.40% were male, the cause was not traumatic in 88%; 65.70% occurred in the patient's home,and in 6% of the cases there had been basic life support. The higher success rate after was achieved in adult male patients (OR: 0,43; CI 95%; 0.25-0.73; P = .002), whose rhythm was shockable (OR: 0,16; CI 95%: 0,09-0,27; P < .001) and when the start time of advanced life support was equal to or less than 10 minutes (OR: 0,22; CI 95%: 0,10-0,49; P < .001). In a multivariant analysis success of CPR was independently associated with male gender, initial shockable rhythm, and the onset of advanced life support within 10 minutes. Nine children were revived, but success was not achieved in any.
Cardiac arrests are more common in adults and in few cases CPR is previously performed. Male gender, an initial shockable rhythm, and the early initiation of advanced life support, are associated with higher success of CPR. There were few CPR performed in cardiac arrest in children, and the prognosis was more unfavorable.

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: Presented at the Annual Meeting of the National Association of EMS Physicians in San Francisco, June 1989.

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Original contributionPrehospital cardiac arrest: The impact of witnessed collapse and bystander CPR in a metropolitan EMS system with short response times

Objective:

Design:

Results:

Conclusion:

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Am J Emerg Med

Ann Emerg Med

Am J Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Lancet

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

JACEP

Am J Emerg Med

Ann Emerg Med

Ann Emerg Med

Am J Emerg Med

Chest

Effects of early defibrillation of out-of-hospital cardiac arrest patients by ambulance personnel

Eur Heart J

A study of out-of-hospital cardiac arrests in north-eastern Minnesota

JAMA

Considerations for improving survival from out-of-hospital cardiac arrest

Ann Emerg Med

Original contribution
Prehospital cardiac arrest: The impact of witnessed collapse and bystander CPR in a metropolitan EMS system with short response times