International variation in survival after out-of-hospital cardiac arrest: A validation study of the Utstein template

Resuscitation for out-of-hospital cardiac arrest in Ireland 2012-2020: Modelling national temporal developments and survival predictors

Aim

To explore potential predictors of national out-of-hospital cardiac arrest (OHCA) survival, including health system developments and the COVID pandemic in Ireland.

Methods

National level OHCA registry data from 2012 through to 2020, relating to unwitnessed, and bystander witnessed OHCA were interrogated. Logistic regression models were built by including predictors through stepwise variable selection and enhancing the models by adding pairwise interactions that improved fit. Missing data sensitivity analyses were conducted using multiple imputation.

Results

The data included 18,177 cases. The final model included seventeen variables. Of these nine variables were involved in pairwise interactions. The COVID-19 period was associated with reduced survival (OR 0.61, 95%CI 0.43, 0.87), as were increasing age in years (OR 0.96, 95% CI 0.96, 0.97) and call response interval in minutes (OR 0.97, 95% CI 0.96, 0.99). Amiodarone administration (OR 3.91, 95% CI 2.80, 5.48), urban location (OR 1.40, 95% CI 1.12, 1.77), and chronological year over time (OR 1.14, 95% CI 1.08, 1.20) were associated with increased survival.

Conclusions

National survival from OHCA has significantly increased incrementally over time in Ireland. The COVID-19 pandemic was associated with decreased survival even after accounting for potential disruption to key elements of bystander and EMS care. Further research is needed to understand and address the discrepancy between urban and rural OHCA survival. Information concerning pre-event patient health status and inpatient care process may yield important additional insights in future.

Emergent Management of Hypoxic-Ischemic Brain Injury

OBJECTIVE

This article outlines interventions used to improve outcomes for patients with hypoxic-ischemic brain injury after cardiac arrest.

LATEST DEVELOPMENTS

Emergent management of patients after cardiac arrest requires prevention and treatment of primary and secondary brain injury. Primary brain injury is minimized by excellent initial resuscitative efforts. Secondary brain injury prevention requires the detection and correction of many pathophysiologic processes that may develop in the hours to days after the initial arrest. Key physiologic parameters important to secondary brain injury prevention include optimization of mean arterial pressure, cerebral perfusion, oxygenation and ventilation, intracranial pressure, temperature, and cortical hyperexcitability. This article outlines recent data regarding the treatment and prevention of secondary brain injury. Different patients likely benefit from different treatment strategies, so an individualized approach to treatment and prevention of secondary brain injury is advisable. Clinicians must use multimodal sources of data to prognosticate outcomes after cardiac arrest while recognizing that all prognostic tools have shortcomings.

ESSENTIAL POINTS

Neurologists should be involved in the postarrest care of patients with hypoxic-ischemic brain injury to improve their outcomes. Postarrest care requires nuanced and patient-centered approaches to the prevention and treatment of primary and secondary brain injury and neuroprognostication.

Epidemiology and outcome of out-of-hospital cardiac arrest in Salt Lake City: Sex-based investigations

Objectives

Prior research indicates sex disparities in the incidence and outcomes of out-of-hospital cardiac arrest (OHCA). This study investigates the presence of such differences in Salt Lake City, Utah.

Methods

We analyzed data from the Salt Lake City Fire Department (2008‒2023). We included adults with non-traumatic OHCA. We calculated the annual incidence of OHCA and examined sex-specific survival outcomes using multivariable logistic regression, adjusting for OHCA characteristics known to be associated with survival.

Results

The annual incidence of OHCA was 76 per 100,000 person-years. Among the 894 OHCA cases included in the analysis, 67.5% were males, 37.3% achieved return of spontaneous circulation (ROSC), and 13.6% survived hospital discharge. Unadjusted analysis revealed that males had significantly higher OHCA in public locations (43.9% vs. 28.6%), witnessed arrests (54.5% vs. 47.8%), and shockable rhythms (33.3% vs. 22.9%). Males also showed higher rates of ROSC (37.5% vs. 36.9%), hospital discharge survival (14.5% vs. 11.7%), and neurologically intact survival. After adjusting for the OHCA characteristics, there was no significant differences between males and females in ROSC, survival to hospital discharge, and favorable neurological function with adjusted odds ratios (male vs. female) of 0.92 (95% confidence interval [CI] 0.73‒1.16), 0.85 (95% CI 0.59‒1.22), and 0.92 (95% CI 0.62‒1.40), respectively.

Conclusion

Approximately, 128 adults suffer OHCA in Salt Lake City annually. Males initially showed higher crude survival rates, but after adjusting for OHCA characteristics, no significant sex differences in survival outcomes were found. Enhancing OHCA characteristics could benefit both sexes. Investigations into the relationship between sex- and region-specific factors influencing OHCA outcomes are needed.

Accuracy of etiological classification of out-of-hospital cardiac arrest: A scoping review

INTRODUCTION

The Utstein reporting template classifies the etiology of OHCA into "presumed cardiac" and "obvious non-cardiac" or "medical" and "non-medical" categories; however, the accuracy of these classifications is unclear. Ascertaining more accurately the etiology of OHCA is important to tailor advanced life support and identify etiologically consistent patient cohorts for reporting incidence and outcome and enrollment in clinical trials. This scoping review was proposed to identify the state of agreement on etiological classification based on emergency medical service (EMS) data using the Utstein format against other sources.

METHOD

We searched Medline, EBM-Cochrane, and Embase databases from 1946-2023 to identify studies that reported initial and confirmed etiologies of OHCA. A descriptive review of the included studies was conducted.

RESULT

The search yielded 22,994 citations. After excluding duplicates, 16,932 citations were reviewed for titles and abstracts. Twelve studies met the inclusion criteria of this review. The frequency of presumed cardiac etiologies based on EMS data was higher than confirmed cardiac etiologies (88% vs 33%) with 83-94% sensitivity and 73-76% specificity. In contrast, the frequency of presumed non-cardiac etiologies was lower than confirmed non-cardiac etiologies (3% vs 27%) with 52-74% sensitivity and 90-97.7% specificity estimated for respiratory disease.

CONCLUSION

Major disparities exist between current etiological classifications based on the Utstein reporting template and robust sources such as autopsy and medical records. Data linkage and validation are necessary to confirm the etiology of OHCA. Further research is needed on how this misclassification affects reported incidence and outcomes, and how contributing factors may improve etiological classifications.

Utility of end-tidal carbon dioxide to guide resuscitation termination in prolonged out-of-hospital cardiac arrest

STUDY OBJECTIVE

To evaluate if the change in end-tidal carbon dioxide (ETCO2) over time has improved discriminatory value for determining resuscitation futility compared to a single ETCO2 value in prolonged, refractory non-shockable out-of-hospital cardiac arrest (OHCA).

METHODS

This is a retrospective analysis of adult refractory non-shockable, non-traumatic OHCA patients in the Portland Cardiac Arrest Epidemiologic Registry (PDX Epistry) from 2018 to 2021. We defined refractory non-shockable OHCA cases as patients with lack of a shockable rhythm at any time or return of spontaneous circulation at any time prior to 30-min of on-scene resuscitation. We abstracted ETCO2 values first recorded after advanced airway placement and nearest to the 30-min mark of on-scene resuscitation (30 min-ETCO2) from EMS charts. The primary outcome was survival to hospital discharge. We compared 30 min-ETCO2 cutoffs of 10 mmHg and 20 mmHg to the trend (increasing or not) from initial to 30 min-ETCO2 (delta-ETCO2) using sensitivity, specificity, and area under the receiver operating curves (AUROC).

RESULTS

Of 3837 adult OHCA, 2850 were initially non-shockable, and there were 617 (16.1%) cases of refractory non-shockable OHCA at 30-min. We excluded 320 cases without at least two ETCO2 recordings in the EMS chart, leaving 297 cases that met inclusion criteria. Of these, 176 (59.3%) were transported and 2 (0.7%) survived to discharge. Using absolute 30 min-ETCO2 cutoffs, both survivors were in the >10 mmHg group (sensitivity 100.0%, specificity 12.5%), whereas only one survivor was identified in the >20 mmHg group (sensitivity 50.0%, specificity 32.5%). Using delta-ETCO2, both survivors were in the increasing ETCO2 group (sensitivity 100.0%, specificity 60.7%). In comparing the two tests that did not misclassify survivors, the AUROC [95% CI] was higher when using delta-ETCO2 (0.803 [0.775-0.831]) compared to an absolute cutoff of 10 mmHg (0.563 [0.544-0.582]).

CONCLUSIONS

Nearly one-sixth of EMS-treated adult OHCA patients had refractory non-shockable arrests after at least 30 min of ongoing resuscitation. In this group, the ETCO2 trend following advanced airway placement may be more accurate in guiding termination of resuscitation than an absolute ETCO2 cutoff of 10 or 20 mmHg.

Ethnic differences of the care pathway following an out-of-hospital cardiac event: A systematic review

AIM

This systematic review aimed to determine to what extent and why the care pathways for acute cardiac events in the community might differ for minoritised ethnic populations compared to non-minoritised populations. It also sought to identify the barriers and enablers that could influence variations in access to care for minoritised populations.

METHODS

A multi-database search was conducted for articles published between 1 January 2000 and 1 January 2023. A combination of MeSH terms and keywords was used. Inclusion criteria for papers were published in English, adult population, the primary health condition was an acute cardiac event, and the primary outcomes were disaggregated by ethnicity or race. A narrative review of extracted data was performed, and findings were reported according to the PRISMA 2020 guidelines.

RESULTS

Of the 3552 articles identified using the search strategy, 40 were deemed eligible for the review. Studies identified a range of variables in the care pathway that differed by ethnicity or race. These could be grouped as time to care, transportation, event related-variables, EMS interactions and symptoms. A meta-analysis was not performed due to heterogeneity across the studies.

CONCLUSION

The extent and reasons for differences in cardiac care pathways are considerable. There are several remediable barriers and enablers that require attention to achieve equitable access to care for minoritised populations.

Comorbidities prior to out-of-hospital cardiac arrest and diagnoses at discharge among survivors

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) has a dismal prognosis with overall survival around 10%. Previous studies have shown conflicting results regarding the prevalence and significance of comorbidities in OHCA, as well as the underlying causes. Previously, 80% of sudden cardiac arrest have been attributed to coronary artery disease. We studied comorbidities and discharge diagnoses in OHCA in all of Sweden.

METHODS

We used the Swedish Registry of Cardiopulmonary Resuscitation, merged with the Inpatient Registry and Outpatient Registry to identify patients with OHCA from 2010 to 2020 and to collect all their comorbidities as well as discharge diagnoses (among those admitted to hospital). Patient characteristics were described using means, medians and SD. Survival curves were performed among hospitalised patients with acute myocardial infarction (AMI) as well as heart failure.

RESULTS

A total of 54 484 patients with OHCA were included, of whom 35 894 (66%) were men. The most common comorbidities prior to OHCA were hypertension (43.6%), heart failure (23.6%), chronic ischaemic heart disease (23.6%) and atrial fibrillation (22.0%). Previous AMI was prevalent in 14.8% of men and 10.9% of women. Among women, 18.0% had type 2 diabetes, compared with 19.6% of the men. Among hospitalised patients, 30% were diagnosed with AMI, 27% with hypertension, 20% with ischaemic heart disease and 18% with heart failure as discharge diagnoses.

CONCLUSION

In summary, we find evidence that nowadays a minority of cardiac arrests are due to coronary artery disease and AMIs and its complications. Only 30% of all cases of OHCA admitted to hospital were diagnosed with AMI. Coronary artery disease is now likely in the minority with regard to causes of OHCA.

Outcomes of out-of-hospital cardiac arrest in Ireland 2012-2020: Protocol for an observational study

Background

Out-of-hospital cardiac arrest (OHCA) is a leading cause of preventable mortality that now affects almost 3,000 people each year in Ireland. Survival is low at 6-7%, compared to a European average of 8%. The Irish Out-of-Hospital Cardiac Registry (OHCAR) prospectively gathers data on all OHCA in Ireland where emergency medical services attempted resuscitation.The Irish health system has undergone several developments that are relevant to OHCA care in the period 2012-2020. OHCAR data provides a means of exploring temporal trends in OHCA incidence, care, and outcomes over time. It also provides a means of exploring whether system developments were associated with a change in key outcomes.This research aims to summarise key trends in available OHCAR data from the period 2012 - 2020, to explore and model predictors of bystander CPR, bystander defibrillation, and survival, and to explore the hypothesis that significant system level temporal developments were associated with improvements in these outcomes.

Methods

The following protocol sets out the relevant background and research approach for an observational study that will address the above aims. Key trends in available OHCAR data (2012 - 2020) will be described and evaluated using descriptive summaries and graphical displays. Multivariable logistic regression will be used to model predictors of 'bystander CPR', 'bystander defibrillation' and 'survival to hospital discharge' and to explore the effects (if any) of system level developments in 2015/2016 and the COVID-19 pandemic (2020) on these outcomes.

Discussion

The findings of this research will be used to understand temporal trends in the care processes and outcomes for OHCA in Ireland over the period 2012-2020. The results can further be used to optimise future health system developments for OHCA in both Ireland and internationally.

Hemoglobin as a prognostic marker for neurological outcomes in post-cardiac arrest patients: a meta-analysis

The aim of this study was to investigate the relationship between serum level of hemoglobin and neurological outcomes following cardiac arrest. Relevant studies were identified by searching electronic databases including PubMed, Web of Science, Cochrane Library, and Embase from June 2012 through April 2023. Articles were rigorously reviewed for their study inclusion and exclusion criteria. Pooled effect date was determined using the standardized mean difference (SMD) and 95% confidence intervals (CI). The Newcastle-Ottawa Scale was used to evaluate study quality. Subgroup analyses were conducted to determine confounding factors affecting patient outcomes. Study heterogeneity, sensitivity, and publication bias were also determined.This meta-analysis included 11 studies involving 2519 patients. Our results suggest that high serum level of hemoglobin may improve neurological prognosis(SMD = 0.60, 95%CI = 0.49-0.71, I2 = 10.85). The findings of this study indicate that serum level of hemoglobin may be associated with better neurological prognosis, perhaps an appropriate increase in serum haemoglobin levels can improve the neurological prognosis of patients in cardiac arrest.

Association of Real-Time Feedback and Cardiopulmonary-Resuscitation Quality Delivered by Ambulance Personnel for Out-of-Hospital Cardiac Arrest

Background High-quality cardiopulmonary resuscitation (CPR) is associated with improved survival from out-of-hospital cardiac arrest and includes chest compression depth, chest compression rate, and chest compression fraction within international guideline recommendations. Previous studies have demonstrated divergent results of real-time feedback on CPR performance and patient outcomes. This study investigated the association between emergency medical service CPR quality and real-time CPR feedback for out-of-hospital cardiac arrest. Methods and Results This study collected out-of-hospital cardiac arrest data within the Capital Region of Denmark and compared CPR quality delivered by ambulance personnel. Data were collected in 2 consecutive phases from October 2018 to February 2020. Median chest compression depth was 6.0 cm (no feedback) and 5.9 cm (real-time feedback) (P=0.852). Corresponding proportion of guideline-compliant chest compressions for depth was 16.6% and 28.7%, respectively (P<0.001). Median chest compression rate per minute was 111 and 109 (P<0.001), respectively. Corresponding guideline adherence proportion for compression rate was 65.4% compared with 80.4% (P<0.001), respectively. Chest compression fraction was 78.9% compared with 81.9% (P<0.001), respectively. The combination of guideline-compliant chest compression depth and chest compression rate simultaneously was 8.5% (no feedback) versus 18.8% (feedback) (P<0.001). Improvements were not significant for return of spontaneous circulation (odds ratio [OR], 1.08 [95% CI, 0.84-1.39]), sustained return of spontaneous circulation (OR, 1.00 [95% CI, 0.77-1.31]), or survival to hospital discharge (OR, 0.91 [95% CI, 0.64-1.30]). Conclusions Real-time feedback was associated with improved guideline compliance for chest compression depth, rate, and fraction but not return of spontaneous circulation, sustained return of spontaneous circulation, or survival to hospital discharge. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04152252.

Prospective comparison of prognostic scores for prediction of outcome after out-of-hospital cardiac arrest: results of the AfterROSC1 multicentric study

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is a heterogeneous entity with multiple origins and prognoses. An early, reliable assessment of the prognosis is useful to adapt therapeutic strategy, tailor intensity of care, and inform relatives. We aimed primarily to undertake a prospective multicentric study to evaluate predictive performance of the Cardiac Arrest Prognosis (CAHP) Score as compare to historical dataset systematically collected after OHCA (Utstein style criteria). Our secondary aim was to evaluate other dedicated scores for predicting outcome after OHCA and to compare them to Utstein style criteria.

METHODS

We prospectively collected data from 24 French and Belgium Intensive Care Units (ICUs) between August 2020 and June 2022. All cases of non-traumatic OHCA (cardiac and non-cardiac causes) patients with stable return of spontaneous circulation (ROSC) and comatose at ICU admission (defined by Glasgow coma score ≤ 8) on ICU admission were included. The primary outcome was the modified Rankin scale (mRS) at day 90 after cardiac arrest, assessed by phone interviews. A wide range of developed scores (CAHP, OHCA, CREST, C-Graph, TTM, CAST, NULL-PLEASE, and MIRACLE2) were included, and their accuracies in predicting poor outcome at 90 days after OHCA (defined as mRS ≥ 4) were determined using the area under the receiving operating characteristic curve (AUROC) and the calibration belt.

RESULTS

During the study period, 907 patients were screened, and 658 were included in the study. Patients were predominantly male (72%), with a mean age of 61 ± 15, most having collapsed from a supposed cardiac cause (64%). The mortality rate at day 90 was 63% and unfavorable neurological outcomes were observed in 66%. The performance (AUROC) of Utstein criteria for poor outcome prediction was moderate at 0.79 [0.76-0.83], whereas AUROCs from other scores varied from 0.79 [0.75-0.83] to 0.88 [0.86-0.91]. For each score, the proportion of patients for whom individual values could not be calculated varied from 1.4% to 17.4%.

CONCLUSIONS

In patients admitted to ICUs after a successfully resuscitated OHCA, most of the scores available for the evaluation of the subsequent prognosis are more efficient than the usual Utstein criteria but calibration is unacceptable for some of them. Our results show that some scores (CAHP, sCAHP, mCAHP, OHCA, rCAST) have superior performance, and that their ease and speed of determination should encourage their use. Trial registration https://clinicaltrials.gov/ct2/show/NCT04167891.

Effectiveness of rescue Me CPR! smartphone app providing real-time guidance to untrained bystanders performing CPR

Background

Out-of-hospital cardiac arrest (OHCA) is a persistent global health challenge, owing, in part, to low rates of population CPR training. Smartphone applications have the potential to widely disseminate CPR basic training to a populace, but other studies have found multiple limitations in previously developed CPR guidance applications (CPR-GA). This study aims to use medical simulation to assess the relative CPR performance of novices using the 'Rescue Me CPR!' (RMC) app, a custom CPR-GA designed by this research team, to novices using 'PG-CPR!' (PGC), the most downloaded CPR-GA available in the USA, and to CPR certified medical personnel.

Methods

In a prospective randomized experimental trial of 60 individuals, subjects were either given the RMC app, the PGC app, or had active CPR certification. They were presented a cardio-pulmonary arrest scenario and were observed while performing CPR on a high-fidelity manikin. Data was collected through four cycles of CPR, during which time 24 pertinent performance metrics and CPR steps were timed and recorded. These metrics were assessed on their own and used to calculate average time to compressions, average chest compression fraction, and rate of high-quality CPR for each study group.

Results

CPR certified subjects called 911 in 100 % of simulation cases, started compressions 34 ± 10 s after first seeing the simulated patient, had an average chest compression fraction of 0.52, and performed high-quality CPR in 25 % of aggregate compression cycles. PGC app users called 911 in 70 % of simulation cases, started compressions 86 ± 17 s after first seeing the simulated patient, had an average chest compression fraction that could not be assessed due to inconsistent pauses during CPR, and performed high-quality CPR in 2.5 % of aggregate compression cycles. RMC app users called 911 in 100 % of simulation cases, started compressions 55 ± 6 s after first seeing the simulated patient, had an average chest compression fraction of 0.48, and performed high-quality CPR in 50 % of aggregate compression cycles.

Conclusion

The results of this study demonstrate that in all studied metrics, except time-to-first-compression, CPR provided by individuals using the RMC app is statistically equivalent or superior to CPR performed by a CPR certified individual and, in almost every metric, superior to CPR performed by users of the most downloaded android CPR guidance application, PG-CPR.

Comparison of four clinical risk scores in comatose patients after out-of-hospital cardiac arrest

BACKGROUND AND AIMS

Several different scoring systems for early risk stratification after out-of-hospital cardiac arrest have been developed, but few have been validated in large datasets. The aim of the present study was to compare the well-validated Out-of-hospital Cardiac Arrest (OHCA) and Cardiac Arrest Hospital Prognosis (CAHP)-scores to the less complex MIRACLE2- and Target Temperature Management (TTM)-scores.

METHODS

This was a post-hoc analysis of the Targeted Hypothermia versus Targeted Normothermia after Out-of-Hospital Cardiac Arrest (TTM2) trial. Missing data were handled by multiple imputation. The primary outcome was discriminatory performance assessed as the area under the receiver operating characteristics-curve (AUROC), with the outcome of interest being poor functional outcome or death (modified Rankin Scale 4-6) at 6 months after OHCA.

RESULTS

Data on functional outcome at 6 months were available for 1829 cases, which constituted the study population. The pooled AUROC for the MIRACLE2-score was 0.810 (95% CI 0.790-0.828), 0.835 (95% CI 0.816-0.852) for the TTM-score, 0.820 (95% CI 0.800-0.839) for the CAHP-score and 0.770 (95% CI 0.748-0.791) for the OHCA-score. At the cut-offs needed to achieve specificities >95%, sensitivities were <40% for all four scoring systems.

CONCLUSIONS

The TTM-, MIRACLE2- and CAHP-scores are all capable of providing objective risk estimates accurate enough to be used as part of a holistic patient assessment after OHCA of a suspected cardiac origin. Due to its simplicity, the MIRACLE2-score could be a practical solution for both clinical application and risk stratification within trials.

Translation and cross-cultural adaptation of the ICHOM standard set for stroke: the Dutch version

INTRODUCTION

The International Consortium for Health Outcomes Measurement (ICHOM) developed a standard set of patient-centered outcome measures for use in stroke patients. In addition to the Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health, it is comprised of 25 questions that are not part of a specific questionnaire. This study aimed to translate these 25 single questions into Dutch.

METHODS

Two native Dutch-speaking translators independently translated the original ICHOM questions into Dutch. A consensus translation was made by these translators and a third person. This translation was subsequently translated back to English independently by two native English-speaking translators. Afterwards a pre-final version was made by consensus of a committee. After field-testing among 30 stroke patients, a final version was made.

RESULTS

The forward and backward translations led to eight cross-cultural adaptations. Based on the interviews with stroke patients, 12 questions were changed to enhance comprehensibility leading to a final Dutch translation of the 25 single questions.

CONCLUSIONS

A Dutch translation of the 25 single questions of the ICHOM Standard Set for Stroke was developed. Now a complete ICHOM Standard Set for Stroke can be used in Dutch populations allowing comparison and improvement of stroke care.

The Lancet Commission to reduce the global burden of sudden cardiac death: a call for multidisciplinary action

Despite major advancements in cardiovascular medicine, sudden cardiac death (SCD) continues to be an enormous medical and societal challenge, claiming millions of lives every year. Efforts to prevent SCD are hampered by imperfect risk prediction and inadequate solutions to specifically address arrhythmogenesis. Although resuscitation strategies have witnessed substantial evolution, there is a need to strengthen the organisation of community interventions and emergency medical systems across varied locations and health-care structures. With all the technological and medical advances of the 21st century, the fact that survival from sudden cardiac arrest (SCA) remains lower than 10% in most parts of the world is unacceptable. Recognising this urgent need, the Lancet Commission on SCD was constituted, bringing together 30 international experts in varied disciplines. Consistent progress in tackling SCD will require a completely revamped approach to SCD prevention, with wide-sweeping policy changes that will empower the development of both governmental and community-based programmes to maximise survival from SCA, and to comprehensively attend to survivors and decedents' families after the event. International collaborative efforts that maximally leverage and connect the expertise of various research organisations will need to be prioritised to properly address identified gaps. The Commission places substantial emphasis on the need to develop a multidisciplinary strategy that encompasses all aspects of SCD prevention and treatment. The Commission provides a critical assessment of the current scientific efforts in the field, and puts forth key recommendations to challenge, activate, and intensify efforts by both the scientific and global community with new directions, research, and innovation to reduce the burden of SCD worldwide.

Organ Donation After Out-of-Hospital Cardiac Arrest: A Scientific Statement From the International Liaison Committee on Resuscitation

AIM OF THE REVIEW

Improving rates of organ donation among patients with out-of-hospital cardiac arrest who do not survive is an opportunity to save countless lives. The objectives of this scientific statement were to do the following: define the opportunity for organ donation among patients with out-of-hospital cardiac arrest; identify challenges and opportunities associated with organ donation by patients with cardiac arrest; identify strategies, including a generic protocol for organ donation after cardiac arrest, to increase the rate and consistency of organ donation from this population; and provide rationale for including organ donation as a key clinical outcome for all future cardiac arrest clinical trials and registries.

METHODS

The scope of this International Liaison Committee on Resuscitation scientific statement was approved by the International Liaison Committee on Resuscitation board and the American Heart Association, posted on ILCOR.org for public comment, and then assigned by section to primary and secondary authors. A unique literature search was completed and updated for each section.

RESULTS

There are a number of defining pathways for patients with out-of-hospital cardiac arrest to become organ donors; however, modifications in the Maastricht classification system need to be made to correctly identify these donors and to report outcomes with consistency. Suggested modifications to the minimum data set for reporting cardiac arrests will increase reporting of organ donation as an important resuscitation outcome. There are a number of challenges with implementing uncontrolled donation after cardiac death protocols, and the greatest impediment is the lack of legislation in most countries to mandate organ donation as the default option. Extracorporeal cardiopulmonary resuscitation has the potential to increase organ donation rates, but more research is needed to derive neuroprognostication rules to guide clinical decision-making about when to stop extracorporeal cardiopulmonary resuscitation and to evaluate cost-effectiveness.

CONCLUSIONS

All health systems should develop, implement, and evaluate protocols designed to optimize organ donation opportunities for patients who have an out-of-hospital cardiac arrest and failed attempts at resuscitation.

Organ Donation After Out-of-Hospital Cardiac Arrest: A Scientific Statement From the International Liaison Committee on Resuscitation

AIM OF THE REVIEW

Improving rates of organ donation among patients with out-of-hospital cardiac arrest who do not survive is an opportunity to save countless lives. The objectives of this scientific statement were to do the following: define the opportunity for organ donation among patients with out-of-hospital cardiac arrest; identify challenges and opportunities associated with organ donation by patients with cardiac arrest; identify strategies, including a generic protocol for organ donation after cardiac arrest, to increase the rate and consistency of organ donation from this population; and provide rationale for including organ donation as a key clinical outcome for all future cardiac arrest clinical trials and registries.

METHODS

The scope of this International Liaison Committee on Resuscitation scientific statement was approved by the International Liaison Committee on Resuscitation board and the American Heart Association, posted on ILCOR.org for public comment, and then assigned by section to primary and secondary authors. A unique literature search was completed and updated for each section.

RESULTS

There are a number of defining pathways for patients with out-of-hospital cardiac arrest to become organ donors; however, modifications in the Maastricht classification system need to be made to correctly identify these donors and to report outcomes with consistency. Suggested modifications to the minimum data set for reporting cardiac arrests will increase reporting of organ donation as an important resuscitation outcome. There are a number of challenges with implementing uncontrolled donation after cardiac death protocols, and the greatest impediment is the lack of legislation in most countries to mandate organ donation as the default option. Extracorporeal cardiopulmonary resuscitation has the potential to increase organ donation rates, but more research is needed to derive neuroprognostication rules to guide clinical decision-making about when to stop extracorporeal cardiopulmonary resuscitation and to evaluate cost-effectiveness.

CONCLUSIONS

All health systems should develop, implement, and evaluate protocols designed to optimise organ donation opportunities for patients who have an out-of-hospital cardiac arrest and failed attempts at resuscitation.

Pre-Arrival Care of the Out-of-Hospital Cardiac Arrest Victim

Lay rescuers play a pivotal role in the recognition and initial management of out-of-hospital cardiac arrest. The provision of timely pre-arrival care by lay responders, including cardiopulmonary resuscitation and the use of automated external defibrillator before emergency medical service arrival, is important link in the chain of survival and has been shown to improve outcomes from cardiac arrest. Although physicians are not directly involved in bystander response to cardiac arrest, they play a key role in emphasizing the importance of bystander interventions.

The development of a risk-adjustment strategy to benchmark emergency medical service (EMS) performance in relation to out-of-hospital cardiac arrest in Australia and New Zealand

INTRODUCTION

The aim of this study was to develop a risk adjustment strategy, including effect modifiers, for benchmarking emergency medical service (EMS) performance for out-of-hospital cardiac arrest (OHCA) in Australia and New Zealand.

METHOD

Using 2017-2019 data from the Australasian Resuscitation Outcomes Consortium (Aus-ROC) OHCA Epistry, we included adults who received an EMS attempted resuscitation for a presumed medical OHCA. Logistic regression was applied to develop risk adjustment models for event survival (return of spontaneous circulation at hospital handover) and survival to hospital discharge/30 days. We examined potential effect modifiers, and assessed model discrimination and validity.

RESULTS

Both OHCA survival outcome models included EMS agency and the Utstein variables (age, sex, location of arrest, witnessed arrest, initial rhythm, bystander cardiopulmonary resuscitation, defibrillation prior to EMS arrival, and EMS response time). The model for event survival had good discrimination according to the concordance statistic (0.77) and explained 28% of the variation in survival. The corresponding figures for survival to hospital discharge/30 days were 0.87 and 49%. The addition of effect modifiers did little to improve the performance of either model.

CONCLUSION

The development of risk adjustment models with good discrimination is an important step in benchmarking EMS performance for OHCA. The Utstein variables are important in risk-adjustment, but only explain a small proportion of the variation in survival. Further research is required to understand what factors contribute to the variation in survival between EMS.

Three-year trends in out-of-hospital cardiac arrest across the world: second report from the International Liaison Committee on Resuscitation (ILCOR)

BACKGROUND

The International Liaison Committee on Resuscitation (ILCOR) Research and Registries Working Group previously reported data on systems of care and outcomes of out-of-hospital cardiac arrest (OHCA) in 2015 from 16 national and regional registries. To describe the temporal trends with updated data on OHCA, we report the characteristics of OHCA from 2015 through 2017.

METHODS

We invited national and regional population-based OHCA registries for voluntary participation and included emergency medical services (EMS)-treated OHCA. We collected descriptive summary data of core elements of the latest Utstein style recommendation during 2016 and 2017 at each registry. For registries that participated in the previous 2015 report, we also extracted the 2015 data.

RESULTS

Eleven national registries in North America, Europe, Asia, and Oceania, and 4 regional registries in Europe were included in this report. Across registries, the estimated annual incidence of EMS-treated OHCA was 30.0-97.1 individuals per 100,000 population in 2015, 36.4-97.3 in 2016, and 40.8-100.2 in 2017. The provision of bystander cardiopulmonary resuscitation (CPR) varied from 37.2% to 79.0% in 2015, from 2.9% to 78.4% in 2016, and from 4.1% to 80.3% in 2017. Survival to hospital discharge or 30-day survival for EMS-treated OHCA ranged from 5.2% to 15.7% in 2015, from 6.2% to 15.8% in 2016, and from 4.6% to 16.4% in 2017.

CONCLUSION

We observed an upward temporal trend in provision of bystander CPR in most registries. Although some registries showed favourable temporal trends in survival, less than half of registries in our study demonstrated such a trend.

Sex Disparities in Prehospital Advanced Cardiac Life Support in Out-of-Hospital Cardiac Arrest in South Korea

OBJECTIVE

Sex disparities have been reported in the prehospital and in-hospital care among patients with out-of-hospital cardiac arrest (OHCA). The aim of this study was to investigate the association between sex and prehospital advanced cardiac life support (ACLS) interventions provided by emergency medical services (EMS).

METHODS

This was a cross-sectional observational study using a nationwide OHCA registry in South Korea. The study included adult OHCAs with presumed cardiac etiology from January 2016 to December 2019. The main exposure was the sex of the victim, and the primary outcomes were prehospital ACLS interventions, including advanced airway management (AAM), intravenous access (IV), and epinephrine (EPI) administration. Multivariable logistic regression analysis accounted for age group, health insurance, comorbidities, place of arrest, urbanization level, witness status, bystander CPR and initial rhythm was performed to calculate adjusted odds ratios (AORs) with 95% confidence intervals (95% CIs).

RESULTS

Among 71,154 eligible patients, females with OHCA received less prehospital ACLS interventions than males: risk difference, (95% CIs) -2.76 (-3.41;-2.11) for AAM, -6.03 (-6.79;-5.27) for IV, and -3.81 (-4.37;-3.25) for EPI. In multivariable logistic regression analysis, female sex was significantly associated with a lower probability of prehospital ACLS provision: AOR, (95% CIs) 0.87 (0.84-0.91) for AAM, 0.85 (0.82-0.88) for IV, and 0.81 (0.77-0.84) for EPI.

CONCLUSION

Compared to male patients, female patients were less likely to receive prehospital ACLS. This offers opportunities for EMS systems to reduce disparities and to improve compliance with OHCA resuscitation guidelines and outcomes through quality improvement and educational interventions.

Differences in Out-of-Hospital Cardiac Arrest Management and Outcomes across Urban, Suburban, and Rural Settings

BACKGROUND

Rural prehospital care settings are underrepresented in the out-of-hospital cardiac arrest (OHCA) literature. This study aimed to describe treatment patterns and the odds of a favorable patient outcome (e.g., return of spontaneous circulation (ROSC) or being presumptively alive at the end of the incident) among rural OHCA patients in the U.S.

METHODS

Using the 2018 National Emergency Medical Services Informational System (NEMSIS) dataset, we analyzed OHCA incidents where an emergency medical services (EMS) unit provided cardiopulmonary resuscitation (CPR) and either terminated the resuscitation or completed transport. We excluded traumatic injuries, pediatric patients, and incidents with response time >60 minutes. The primary outcome was ROSC at any time during the EMS incident. The secondary outcome was a binary end-of-event indicator previously described for use in NEMSIS to estimate longer-term outcomes. Multivariable logistic regression was performed for each outcome measure comparing rural, suburban, and urban settings while controlling for key factors.

RESULTS

A total of 64,489 OHCA incidents were included, with 5,601 (8.9%) in rural settings. Among the full sample of OHCA incidents, ROSC was achieved in 20,578 (33.6%) cases, including 29.2% in rural settings and 34.1% in urban or suburban settings (p < 0.001). Advanced life support units responded to 95.3% of all calls, and a greater proportion of rural OHCA incidents were managed by basic life support units (7.4% vs. 4.2%, p < 0.001). Rural OHCA incidents had longer response times (7.5 vs. 5.9 minutes, p < 0.001), and rural patients were less likely to receive epinephrine (69.3% vs. 73.3%, p < 0.001). Further, EMS clinicians in rural areas were more likely to use mechanical CPR (29.5% vs. 27.6%, p < 0.01) and were less likely to perform advanced airway management (48.5% vs. 54.2%, p < 0.001). Rural patients had lower odds of achieving ROSC than urban patients after controlling for other factors (OR 0.81, 95% CI: 0.75-0.87). Rural patients also had lower odds of having a positive end-of-event outcome (i.e., presumptively alive) after controlling for other factors (OR 0.86, 95% CI: 0.79-0.93).

CONCLUSION

In this national sample of EMS-treated OHCAs, rural patients had lower odds of a favorable outcome (e.g., ROSC or presumptively alive) compared to those in urban settings.

Impact of defibrillation with automated external defibrillator by bystander before defibrillation by emergency medical system personnel on neurological outcome of out-of-hospital cardiac arrest with non-cardiac etiology

Aim of the study

Although defibrillation using automated external defibrillator (AED) by bystander prior to emergency medical system (EMS) arrival was associated with favorable outcomes in out-of-hospital cardiac arrest (OHCA) of cardiac cause, whether it improves outcomes of OHCA due to non-cardiac cause is not clear. We aimed to investigate the impact of defibrillation with AED by bystander before defibrillation by EMS personnel on the outcomes of OHCA of presumed non-cardiac cause.

Methods

This was a retrospective cohort study using the All-Japan Utstein registry (reference period: 2013 to 2017). We included adult patients with OHCA of presumed non-cardiac cause, who had initial shockable rhythm, and who received witnessed arrest bystander cardiopulmonary resuscitation (CPR). Exposure variable was defibrillation with AED by bystander in comparison with initial defibrillation by EMS. Logistic regression analyses were conducted to assess the association between bystander AED shock and favorable neurological outcome (Cerebral Performance Category scale 1 or 2) at one month.

Results

Among the 1,053 patients included for analysis, 57 (5.4%) received bystander AED shock. There was no statistically significant difference in the rate of favorable neurological outcome at one month between groups [9 (15.8%) vs 109 (10.9%), p = 0.26]. Logistic regression analysis adjusted for characteristics, intervention, and time course of CPR showed no association between bystander AED shock and favorable neurological outcome [OR (95% CI): 1.63 (0.70-3.77), p = 0.25].

Conclusion

In this study, defibrillation with AED by bystander before defibrillation by EMS personnel was not associated with the favorable outcomes of OHCA of presumed non-cardiac cause.

Sex disparities in prehospital advanced cardiac life support in out-of-hospital cardiac arrests in Japan

OBJECTIVE

Sex disparities in out-of-hospital cardiac arrest (OHCA) care processes have been reported. This study aimed to investigate the association between sex and prehospital advanced cardiac life support (ACLS) interventions provided by emergency medical services in Japan.

METHODS

We analyzed data from January 1, 2013, to December 31, 2020, from the All-Japan Utstein Registry of patients with OHCA aged ≥18 years who were resuscitated by bystanders. The primary outcomes were prehospital ACLS interventions, including advanced airway management (AAM) and epinephrine administration. Sex-based disparities in receiving prehospital ACLS interventions were assessed via multivariable logistic regression analyses.

RESULTS

Among 314,460 eligible patients, females with OHCA received fewer prehospital ACLS interventions than males: 83,571/187,834 (44.5%) males vs. 55,086/126,626 (43.5%) females (adjusted odds ratio [AOR] = 0.94, 95% confidence interval [CI] = 0.93-0.96) for AAM and 60,097/187,834 (32.0%) males vs. 35,501/126,626 (28.0%) females (AOR = 0.84, 95% CI = 0.83-0.85) for epinephrine administration. Similar results were also obtained in the subgroup analysis (groups included patients aged 18-74 years and ≥75 years and those with cardiac origin, ventricular fibrillation (VF), non-VF, non-family member witnessed, and family member witnessed).

CONCLUSION

Compared with males, females were less likely to receive prehospital ACLS. Emergency medical service staff must be made aware of this disparity, and off-the-job training on intravenous cannulation or AAM replacement must be conducted. Investigation of the impact of sex disparity on OHCA care processes can facilitate planning of future public health policies to improve survival outcomes.

Successful treatment of out-of-hospital cardiac arrest is still based on quick activation of the chain of survival

Background and goal of study

Cardiopulmonary resuscitation (CPR) in prehospital care is a major reason for emergency medical service (EMS) dispatches. CPR outcome depends on various factors, such as bystander CPR and initial heart rhythm. Our aim was to investigate whether short-term outcomes such as the return of spontaneous circulation (ROSC) and hospital admission with spontaneous circulation differ depending on the location of the out-of-hospital cardiac arrest (OHCA). In addition, we assessed further aspects of CPR performance.

Materials and methods

In this monocentric retrospective study, protocols of a prehospital physician-staffed EMS located in Munich, Germany, were evaluated using the Mann-Whitney U-test, chi-square test, and a multifactor logistic regression model.

Results and discussion

Of the 12,073 cases between 1 January 2014 and 31 December 2017, 723 EMS responses with OHCA were analyzed. In 393 of these cases, CPR was performed. The incidence of ROSC did not differ between public and non-public spaces (p = 0.4), but patients with OHCA in public spaces were more often admitted to the hospital with spontaneous circulation (p = 0.011). Shockable initial rhythm was not different between locations (p = 0.2), but defibrillation was performed significantly more often in public places (p < 0.001). Multivariate analyses showed that hospital admission with spontaneous circulation was more likely in patients with shockable initial heart rhythm (p < 0.001) and if CPR was started by an emergency physician (p = 0.006).

Conclusion

The location of OHCA did not seem to affect the incidence of ROSC, although patients in public spaces had a higher chance to be admitted to the hospital with spontaneous circulation. Shockable initial heart rhythm, defibrillation, and the start of resuscitative efforts by an emergency physician were associated with higher chances of hospital admission with spontaneous circulation. Bystander CPR and bystander use of automated external defibrillators were low overall, emphasizing the importance of bystander education and training in order to enhance the chain of survival.

The incidence and outcomes of out-of-hospital cardiac arrest in metropolitan versus rural locations: A systematic review and meta-analysis

BACKGROUND/AIMS

Rurality poses a unique challenge to the management of out-of-hospital cardiac arrest (OHCA) when compared to metropolitan (metro) locations. We conducted a systematic review of published literature to understand how OHCA incidence, management and survival outcomes vary between metro and rural areas.

METHODS

We included studies comparing the incidence or survival of ambulance attended OHCA in metropolitan and rural areas, from a search of five databases from inception until 9th March 2022. The primary outcomes of interest were cumulative incidence and survival (return of spontaneous circulation, survival to hospital discharge (or survival to 30 days)). Meta-analyses of OHCA survival were undertaken.

RESULTS

We identified 28 studies (30 papers- total of 823,253 patients) across 13 countries of origin. The definition of rurality varied markedly. There was no clear difference in OHCA incidence between metro and rural locations. Whilst there was considerable statistical heterogeneity between studies, the likelihood of return of spontaneous circulation on arrival at hospital was lower in rural than metro locations (OR = 0.53, 95% CI 0.40, 0.70; I² = 89%; 5 studies; 90,934 participants), as was survival to hospital discharge/survival to 30 days (OR = 0.52, 95% CI 0.38, 0.71; I² = 95%; 15 studies; 18,837 participants).

CONCLUSIONS

Overall, while incidence did not vary, the odds of OHCA survival to hospital discharge were approximately 50% lower in rural areas compared to metro areas. This suggests an opportunity for improvement in the prehospital management of OHCA within rural locations. This review also highlighted major challenges in standardising the definition of rurality in the context of cardiac arrest research.

Short- and long-term survival after out-of-hospital cardiac arrest in Kaunas (Lithuania) from 2016 to 2018

BACKGROUND

No studies analysing out-of-hospital cardiac arrest (OHCA) epidemiology and outcomes in Lithuania were published in the last decade.

METHODS

We conducted a retrospective analysis of prospectively collected data. The incidence of OHCA and the demographics and outcomes of patients who were treated for OHCA between 1 and 2016 and 31 December 2018 at Kaunas Emergency Medical Service (EMS) were collected and are reported in accordance with the Utstein recommendations. Multivariable logistic regression analysis was used to identify predictors of survival to hospital discharge.

RESULTS

In total, 838 OHCA cases of EMS-treated cardiac arrest (CA) were reported (95.8 per 100.000 inhabitants). The median age was 71 (IQR 58-81) years of age, and 66.7% of patients were males. A total of 73.8% of OHCA cases occurred at home, 59.3% were witnessed by a bystander, and 54.5% received bystander cardiopulmonary resuscitation. The median EMS response time was 10 min. Cardiac aetiology was the leading cause of CA (78.8%). The initial rhythm was shockable in 27.6% of all cases. Return of spontaneous circulation at hospital transfer was evident in 24.9% of all cases. The survival to hospital discharge rate was 10.9%, and the 1-year survival rate was 6.9%. The survival to hospital discharge rate in the Utstein comparator group was 36.1%, and the 1-year survival rate was 27.2%. Five factors were associated with improved survival to hospital discharge: shockable rhythm, time from call to arrival at the patient less than 10 min, witnessed OHCA, age < 80 years, and male sex.

CONCLUSION

This is the first OHCA study from Lithuania examining OHCA epidemiology and outcomes over a three year period. Routine OHCA data collection and analysis will allow us to track the efficacy of service improvements and should become a standard practice in all Lithuanian regions.

TRIAL REGISTRATION

This research was registered in the clinicaltrials.gov database: Identifiers: NCT04784117, Unique Protocol ID: LITOHCA. Brief Title: Out-of-hospital Cardiac Arrest Epidemiology and Outcomes in Kaunas 2016-2021.

Firefighters as first-responders in out-of-hospital cardiac arrest- a retrospective study of a time-gain selective dispatch system in the Skåne Region, Sweden

AIM

To analyze the impact of a time-gain selective, first-responder dispatch system on the presence of a shockable initial rhythm (SIR), return of spontaneous circulation (ROSC) and 30-day survival after out-of-hospital cardiac arrest (OHCA).

METHOD

A retrospective observational study comprising OHCA registry data and dispatch data in the Skåne Region, Sweden (2010-2018). Data were categorized according to dispatch procedures, two ambulances (AMB-only) versus two ambulances and firefighter first-responders (DUAL-dispatch), based on the dispatcher's estimation of a time-gain. Dual dispatch was sub-categorized by arrival of first vehicle (first-responder or ambulance). Logistic regressions were used, additionally with groups matched (1:1) for age, witnessed event, bystander cardiopulmonary resuscitation and ambulance response time. Adjusted and conditional odds-ratios (aOR, cOR) with 95% confidence intervals (CI) are presented.

RESULTS

Of 3,245 eligible cases, 43% were DUAL-dispatches with first-responders first on scene (FR-first) in 72%. Despite a five-minute median reduction in response time in the FR-first group, no association with SIR was found (aOR 0.83, 95%CI 0.64-1.07) nor improved 30-day survival (aOR 1.03, 95%CI 0.72-1.47). A positive association between ROSC and the FR-first group (aOR 1.25, 95%CI 1.02-1.54) disappeared in the matched analysis (cOR 1.12, 95%CI 0.87-1.43). Time to first monitored rhythm was 7:06 minutes in the FR-first group versus 3:01 in the combined AMB-only/AMB-first groups.

CONCLUSION

In this time-gain selective first-responder dispatch system, a shorter response time was not associated with increased SIR, improved ROSC rate or survival. Process measures differed between the study groups which could account for the observed findings and requires further investigation.

Effect of Coaching with Repetitive Verbal Encouragements on Dispatch-Assisted Cardiopulmonary Resuscitation: A Randomized Simulation Study

BACKGROUND

Current guidelines emphasize the assistance of the emergency dispatcher in bystander cardiopulmonary resusitation (CPR). Its quality, however, has varied across cases.

OBJECTIVE

To determine the effect of repetitive coaching by dispatchers using verbal encouragement on the quality of lay-rescuer CPR.

METHODS

We conducted a dispatch-assisted CPR (DACPR) simulation study. Participants with no CPR training within the previous year were assigned randomly to 1 of 2 DACPR simulations. One was the No Coaching Group: callers were told to perform CPR and the dispatcher periodically confirmed that the caller was performing CPR. The second group was the Coaching Group: the dispatcher repetitively coached, encouraged, and counted aloud using a metronome. Participants performed CPR for 2 min under instruction from the study dispatcher. Parameters including chest compression depth, rate, and chest compression fraction were recorded by video camera and CPR manikin.

RESULTS

Forty-nine participants 20 to 50 years of age were recruited, and 48 completed the simulation (Coaching Group, n = 27; No Coaching Group, n = 21). The chest compression fraction was higher in the Coaching Group (99.4% vs. 93.0%, p = 0.005) and no participants interrupted chest compression more than 10 s in this group. When comparing the average depth of each 30-s period in each group, the depth increased over time in the Coaching Group (40.9 mm, 43.9 mm, 44.1 mm, and 42.8 mm), while it slightly decreased in the No Coaching Group (40.6 mm, 40.1 mm, 39.4 mm, and 39.8 mm).

CONCLUSIONS

Repetitive verbal encouragements augmented chest compression depth with less-hands off time. Continuous coaching by dispatchers can optimize lay-rescuer CPR. © 2022 Elsevier Inc.

International Initiation and Termination of Resuscitation Practices

BACKGROUND

Substantial variation in survival following out-of-hospital cardiac arrest is described both internationally and nationally. The Utstein factors account for half of the variation, but the remaining is not fully understood. Local regulations or guidelines concerning the withholding and termination of resuscitation may influence the reporting of cardiac arrests when comparing outcomes between different EMS systems.

METHOD

We have developed an online cross-sectional mixed-methods explanatory design survey aimed at describing the international and national variations in the initiation, the termination of resuscitation, and the refraining from resuscitation of adult patients (>18 years of age) suffering from non-traumatic OHCA. The respondents will be national experts and the questionnaire will be distributed among members of EUPHOREA, the International Liaison Committee of Resuscitation (ILCOR), the European Resuscitation Council, and the Resuscitation Academy. Each invited country will have to identify at least two national experts with special expertise in prehospital resuscitation practices. We exclude countries with less than two respondents.

RESULTS

The survey will provide both quantitative and qualitative data. Quantitative data will be presented as frequencies and proportions. Qualitative data will be analyzed using content analysis.

CONCLUSION

This survey could be of importance in understanding the multiple factors leading to the substantial variation in survival found following OHCA. Furthermore, the interpretation of future studies on OHCA from different settings may be improved to further increase survival following OHCA.

Out-of-Sample Validity of the PROLOGUE Score to Predict Neurologic Function after Cardiac Arrest

Background: The clinical value of a prognostic score depends on its out-of-sample validity because inaccurate outcome prediction can be not only useless but potentially fatal. We aimed to evaluate the out-of-sample validity of a recently developed and highly accurate Korean prognostic score for predicting neurologic outcome after cardiac arrest in an independent, plausibly related sample of European cardiac arrest survivors. Methods: Analysis of data from a European cardiac arrest center, certified in compliance with the specifications of the German Council for Resuscitation. The study sample included adults with nontraumatic out-of-hospital cardiac arrest admitted between 2013 and 2018. Exposure was the PROgnostication using LOGistic regression model for Unselected adult cardiac arrest patients in the Early stages (PROLOGUE) score, including 12 clinical variables readily available at hospital admission. The outcome was poor 30-day neurologic function, as assessed using the cerebral performance category scale. The risk of a poor outcome was calculated using the PROLOGUE score regression equation. Predicted risk deciles were compared to observed outcome estimates in a complete-case analysis, a best-case analysis, and a multiple-data-imputation analysis using the Markov chain Monte Carlo method. Results: A total of 1051 patients (median 61 years, IQR 50–71; 29% female) were analyzed. A total of 808 patients (77%) were included in the complete-case analysis. The PROLOGUE score overestimated the risk of poor neurologic outcomes in the range of 40% to 100% predicted risk, involving 63% of patients. The model fit did not improve after missing data imputation. Conclusions: In a plausibly related sample of European cardiac arrest survivors, risk prediction by the PROLOGUE score was largely too pessimistic and failed to replicate the high accuracy found in the original study. Using the PROLOGUE score as an example, this study highlights the compelling need for independent validation of a proposed prognostic score to prevent potentially fatal mispredictions.

Long Term Cognitive Function After Cardiac Arrest: A Mini-Review

Out-of-hospital cardiac arrest (OHCA) is a leading cause of mortality worldwide. With better pre- and inhospital treatment, including cardiopulmonary resuscitation (CPR) as an integrated part of public education and more public-access defibrillators available, OHCA survival has increased over the last decade. There are concerns, after successful resuscitation, of cerebral hypoxia and degrees of potential acquired brain injury with resulting poor cognitive functioning. Cognitive function is not routinely assessed in OHCA survivors, and there is a lack of consensus on screening methods for cognitive changes. This narrative mini-review, explores available evidence on hypoxic brain injury and long-term cognitive function in cardiac arrest survivors and highlights remaining knowledge deficits.

A chart review tool to systematically assess the safety of prehospital care for children with out‐of‐hospital cardiac arrest

Objective

Create an easy‐to‐use pediatric out‐of‐hospital cardiac arrest (OHCA)‐specific chart review tool to reliably detect severe adverse safety events (ASEs) in the prehospital care of children with OHCA.

Methods

We revised our previously validated pediatric prehospital adverse event detection system (PEDS) tool, used to evaluate ASEs in the prehospital care of children during emergent calls, to create an OHCA‐specific chart review tool. We developed decision support for reviewers, reviewer training, and a dedicated section for chart data abstraction. We randomly selected 28 charts for independent review by 2 expert reviewers who determined the presence or absence of a severe ASE for each care episode and identified the domain of care and preventability for each ASE. We calculated inter‐rater agreement in the assessment of the presence or absence of a severe ASE using Gwet's first‐order agreement coefficient (AC1).

Results

The PEDS‐OHCA chart review tool has 6 sections, with a minimum of 70 and maximum of 667 total possible fields. We found inter‐rater agreement of 0.83 (95% confidence interval, 0.63–0.99) between our 2 reviewers for the overall detection of a severe ASE and an average time to complete of 8 minutes (range, 2–25 minutes). Inter‐rater agreement in the detection of a severe ASE in each individual domain ranged from 0.36 to 0.96.

Conclusions

The PEDS‐OHCA is the first chart review tool to systematically evaluate the safety and quality of EMS care for children with OHCA. This tool may help improve understanding of the quality of EMS care for children with OHCA, which is essential to improving outcomes.

Global variation in the incidence and outcome of emergency medical services witnessed out-of-hospital cardiac arrest: A systematic review and meta-analysis

AIM OF THE REVIEW

To examine global variation in the incidence and outcomes of emergency medical services (EMS) witnessed out-of-hospital cardiac arrest (OHCA).

DATA SOURCES

We systematically reviewed four electronic databases for studies between 1990 and 5th April 2021 reporting EMS-witnessed OHCA populations. Studies were included if they reported sufficient data to calculate the primary outcome of survival to hospital discharge or 30-day survival. Random-effects models were used to pool incidence and survival outcomes, and meta-regression was used to examine sources of heterogeneity. Study quality was appraised using the Joanna Briggs Institute critical appraisal tools.

RESULTS

The search returned 1178 non-duplicate titles of which 66 articles comprising 133,981 EMS-witnessed patients treated by EMS across 33 countries were included. All but one study was observational and only 12 studies (18%) were deemed to be at low risk of bias. The pooled incidence of EMS-treated cases was 4.1 per 100,000 person-years (95% CI: 3.5, 4.7), varying almost 4-fold across continents. The pooled proportion of survivors to hospital discharge or 30-days was 20% overall (95% CI: 18%, 22%; I² = 98%), 43% (95% CI: 37%, 49%; I² = 94%) for initial shockable rhythms and 6% (95% CI: 5%, 8%; I² = 79%) for initial non-shockable rhythms. In the meta-regression analysis, only region and aetiology were significantly associated with survival. When compared to studies from North America, pooled survival was significantly higher in studies from Europe (14% vs. 26%; p = 0.04) and Australasia (14% vs. 31%, p < 0.001).

CONCLUSION

We identified significant global variation in the incidence and survival outcome of EMS-witnessed OHCA. Further research is needed to understand the factors contributing to these variations.

Mode of transportation of out-of-hospital cardiac arrest patients, the role of community actions and interventions

The Emergency Medical Services constitutes a critical component in treating patients with out-of-hospital cardiac arrest (OHCA). Activating the EMS system is the first important step in deploying resources, but community involvement in the care of emergent patients is multifaceted and complex. How does the public access EMS services versus other modes of transport remains under investigated; and if the public opts for a different mode of transport to the hospital, how does this affect outcomes?

Incidence, characteristics and outcomes of out-of-hospital cardiac arrests in patients with psychiatric illness: A systematic review

Aim

To conduct a systematic literature review of the existing evidence on incidence, characteristics and outcomes after out-of-hospital cardiac arrest (OHCA) in patients with psychiatric illness.

Methods

We searched Embase, Medline, PsycINFO and Web of Science using a comprehensive electronic search strategy to identify observational studies reporting on OHCA incidence, characteristics or outcomes by psychiatric illness status. One reviewer screened all titles and abstracts, and a second reviewer screened a random 10%. Two reviewers independently performed data extraction and quality assessment.

Results

Our search retrieved 11,380 studies, 10 of which met our inclusion criteria (8 retrospective cohort studies and two nested case-control studies). Three studies focused on depression, whilst seven included various psychiatric conditions. Among patients with an OHCA, those with psychiatric illness (compared to those without) were more likely to have: an arrest in a private location; an unwitnessed arrest; more comorbidities; less bystander cardiopulmonary resuscitation; and an initial non-shockable rhythm. Two studies reported on OHCA incidence proportion and two reported on survival, showing higher risk, but lower survival, in patients with psychiatric illness.

Conclusion

Psychiatric illness in relation to OHCA incidence and outcomes has rarely been studied and only a handful of studies have reported on OHCA characteristics, highlighting the need for further research in this area. The scant existing literature suggests that psychiatric illness may be associated with higher risks of OHCA, unfavourable characteristics and poorer survival. Future studies should further investigate these links and the role of potential contributory factors such as socioeconomic status and comorbidities.

Optimizing Outcomes After Out-of-Hospital Cardiac Arrest With Innovative Approaches to Public-Access Defibrillation: A Scientific Statement From the International Liaison Committee on Resuscitation

Out-of-hospital cardiac arrest is a global public health issue experienced by ≈3.8 million people annually. Only 8% to 12% survive to hospital discharge. Early defibrillation of shockable rhythms is associated with improved survival, but ensuring timely access to defibrillators has been a significant challenge. To date, the development of public-access defibrillation programs, involving the deployment of automated external defibrillators into the public space, has been the main strategy to address this challenge. Public-access defibrillator programs have been associated with improved outcomes for out-of-hospital cardiac arrest; however, the devices are used in <3% of episodes of out-of-hospital cardiac arrest. This scientific statement was commissioned by the International Liaison Committee on Resuscitation with 3 objectives: (1) identify known barriers to public-access defibrillator use and early defibrillation, (2) discuss established and novel strategies to address those barriers, and (3) identify high-priority knowledge gaps for future research to address. The writing group undertook systematic searches of the literature to inform this statement. Innovative strategies were identified that relate to enhanced public outreach, behavior change approaches, optimization of static public-access defibrillator deployment and housing, evolved automated external defibrillator technology and functionality, improved integration of public-access defibrillation with existing emergency dispatch protocols, and exploration of novel automated external defibrillator delivery vectors. We provide evidence- and consensus-based policy suggestions to enhance public-access defibrillation and guidance for future research in this area.

Optimizing outcomes after out-of-hospital cardiac arrest with innovative approaches to public-access defibrillation: A scientific statement from the International Liaison Committee on Resuscitation

Out-of-hospital cardiac arrest is a global public health issue experienced by ≈3.8 million people annually. Only 8% to 12% survive to hospital discharge. Early defibrillation of shockable rhythms is associated with improved survival, but ensuring timely access to defibrillators has been a significant challenge. To date, the development of public-access defibrillation programs, involving the deployment of automated external defibrillators into the public space, has been the main strategy to address this challenge. Public-access defibrillator programs have been associated with improved outcomes for out-of-hospital cardiac arrest; however, the devices are used in <3% of episodes of out-of-hospital cardiac arrest. This scientific statement was commissioned by the International Liaison Committee on Resuscitation with 3 objectives: (1) identify known barriers to public-access defibrillator use and early defibrillation, (2) discuss established and novel strategies to address those barriers, and (3) identify high-priority knowledge gaps for future research to address. The writing group undertook systematic searches of the literature to inform this statement. Innovative strategies were identified that relate to enhanced public outreach, behavior change approaches, optimization of static public-access defibrillator deployment and housing, evolved automated external defibrillator technology and functionality, improved integration of public-access defibrillation with existing emergency dispatch protocols, and exploration of novel automated external defibrillator delivery vectors. We provide evidence- and consensus-based policy suggestions to enhance public-access defibrillation and guidance for future research in this area.

Out-of-Hospital Cardiac Arrests Terminated without full Resuscitation Attempts: Characteristics and Regional Variability

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) investigations may elect to exclude cases with resuscitation terminated for reasons other than a full resuscitative attempt. We sought to examine characteristics of these cases and regional variability in classification.

METHODS

Using the North American Resuscitation Outcomes Consortium Epistry, we included adult emergency medical services (EMS)-treated cases, examining the rationale ("futility", do-not resuscitate (DNR) order, "verbal directive", or "obvious death") and timing of resuscitation termination, and the timing of ROSC among hospital-discharge survivors. We tested regional variability in EMS patient arrival-to-termination intervals with one-way ANOVA.

RESULTS

Of 63,554 included cases, 27,232 were declared dead in the prehospital setting: (1) 23,009 (36%) for futility (after a median of 24 minutes (IQR 19-31) of professional resuscitation); (2) 1622 (2.6%) for a DNR order (at 6.3 minutes [IQR 3.0-11]); (3) 1018 (1.6%) for a verbal directive (at 12 minutes [IQR 7.0-17]); and, (4) 1583 (2.5%) for obvious death (at 5.4 minutes [IQR 3.0-9.0]). The EMS patient arrival-to-ROSC interval among hospital-discharge survivors was 7.7 (3.8 - 13) minutes. Among regions, 0.20-12% and 0.20-5.3% were terminated to due to obvious death or verbal directives, respectively. There were significant regional differences in the EMS patient arrival-to-termination interval for futility (p<0.010) and obvious death (p<0.010).

CONCLUSION

There is significant variation in the rationale and interval until termination of resuscitation between regions. Cases terminated due to obvious death or DNR orders/verbal directives often are treated with similar durations of resuscitation as survivors. These data highlight a considerable risk of bias in between-region comparisons or observational analyses.

Cold Weather and Cardiac Arrest in 4 Seasons: Helsinki, Finland, 1997‒2018

Objectives. To test the a priori hypothesis that out-of-hospital cardiac arrest (OHCA) is associated with cold weather during all seasons, not only during the winter. Methods. We applied a case‒crossover design to all cases of nontraumatic OHCA in Helsinki, Finland, over 22 years: 1997 to 2018. We statistically defined cold weather for each case and season, and applied conditional logistic regression with 2 complementary models a priori according to the season of death. Results. There was an association between cold weather and OHCA during all seasons, not only during the winter. Each additional cold day increased the odds of OHCA by 7% (95% confidence interval [CI] = 4%, 10%), with similar strength of association during the autumn (6%; 95% CI = 0%, 12%), winter (6%; 95% CI = 1%, 12%), spring (8%; 95% CI = 2%, 14%), and summer (7%; 95% CI = 0%, 15%). Conclusions. Cold weather, defined according to season, increased the odds of OHCA during all seasons in similar quantity. Public Health Implications. Early warning systems and cold weather plans focus implicitly on the winter season. This may lead to incomplete measures in reducing excess mortality related to cold weather. (Am J Public Health. 2022;112(1):107-115. https://doi.org/10.2105/AJPH.2021.306549).

Outcomes and interventions in patients transported to hospital with ongoing CPR after out-of-hospital cardiac arrest - An observational study

Introduction

The main objective was to present characteristics and outcome of patients without sustained field return of spontaneous circulation (ROSC) transported to hospital with ongoing cardiopulmonary resuscitation (CPR). Our secondary objectives were to investigate hospital-based interventions and the performance of the universal Termination of Resuscitation-rule (uTOR).

Methods

In this retrospective observational cohort study, out-of-hospital cardiac arrest (OHCA) patients arriving to the emergency department of a university hospital in Sweden during a six-year period (2010–2015) were identified using a prospectively recorded hospital-based registry. Additional data were retrieved from medical records and from the Swedish cardiopulmonary resuscitation registry.

Results

Among 409 patients transported with ongoing CPR, 7 survived to hospital discharge (1.7%). Hospital-based interventions against a suspected cause of arrest were attempted during ongoing resuscitation in 34 patients (8.3%), of whom 3 survived to hospital discharge. The remaining 4 survivors had spontaneous in-hospital ROSC. Survivors presented with either a shockable rhythm (n = 4) or pulseless electrical activity (n = 3). The uTOR identified non-survivors with a positive predictive value (PPV) of 98.4% and a specificity of 71.4% for termination.

Conclusion

Survival after OHCA where sustained prehospital ROSC is not achieved is rare and available in-hospital interventions are rarely utilised. No patient with asystole as the first recorded rhythm survived. The uTOR identified non-survivors with a PPV of 98.4% but showed poor specificity.

Intensive care-treated cardiac arrest: a retrospective study on the impact of extended age on mortality, neurological outcome, received treatments and healthcare-associated costs

Background

Cardiac arrest (CA) is a leading cause of death worldwide. As population ages, the need for research focusing on CA in elderly increases. This study investigated treatment intensity, 12-month neurological outcome, mortality and healthcare-associated costs for patients aged over 75 years treated for CA in an intensive care unit (ICU) of a tertiary hospital.

Methods

This single-centre retrospective study included adult CA patients treated in a Finnish tertiary hospital’s ICU between 2005 and 2013. We stratified the study population into two age groups: <75 and \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\ge$$\end{document}≥75 years. We compared interventions defined by the median daily therapeutic scoring system (TISS-76) between the age groups to find differences in treatment intensity. We calculated cost-effectiveness by dividing the total one-year healthcare-associated costs of all patients by the number of survivors with a favourable neurological outcome. Favourable outcome was defined as a cerebral performance category (CPC) of 1–2 at 12 months after cardiac arrest. Logistic regression analysis was used to identify independent associations between age group, mortality and neurological outcome.

Results

This study included a total of 1,285 patients, of which 212 (16 %) were \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\ge$$\end{document}≥75 years of age. Treatment intensity was lower for the elderly compared to the younger group, with median TISS scores of 116 and 147, respectively (p < 0.001). The effective cost in euros for patients with a good one-year neurological outcome was €168,000 for the elderly and €120,000 for the younger group. At 12 months after CA 24 % of the patients in the elderly group and 47 % of the patients in the younger group had a CPC of 1–2 (p < 0.001). Age was an independent predictor of mortality (multivariate OR = 2.90, 95 % CI: 1.94–4.31, p < 0.001) and neurological outcome (multivariate OR = 3.15, 95 % CI: 2.04–4.86, p < 0.001).

Conclusions

The elderly ICU-treated CA patients in this study had worse neurological outcomes, higher mortality and lower cost-effectiveness than younger patients. Elderly received less intense treatment. Further efforts are needed to recognize the tools for assessing which elderly patients benefit from a more aggressive treatment approach in order to improve the cost-effectiveness of post-CA management.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00923-0.

To ventilate or not to ventilate during bystander CPR - A EuReCa TWO analysis

BACKGROUND

Survival after out-of-hospital cardiac arrest (OHCA) is still low. For every minute without resuscitation the likelihood of survival decreases. One critical step is initiation of immediate, high quality cardiopulmonary resuscitation (CPR). The aim of this subgroup analysis of data collected for the European Registry of Cardiac Arrest Study number 2 (EuReCa TWO) was to investigate the association between OHCA survival and two types of bystander CPR namely: chest compression only CPR (CConly) and CPR with chest compressions and ventilations (FullCPR).

METHOD

In this subgroup analysis of EuReCa TWO, all patients who received bystander CPR were included. Outcomes were return of spontaneous circulation and survival to 30-days or hospital discharge. A multilevel binary logistic regression analysis with survival as the dependent variable was performed.

RESULTS

A total of 5884 patients were included in the analysis, varying between countries from 21 to 1444. Survival was 320 (8%) in the CConly group and 174 (13%) in the FullCPR group. After adjustment for age, sex, location, rhythm, cause, time to scene, witnessed collapse and country, patients who received FullCPR had a significantly higher survival rate when compared to those who received CConly (adjusted odds ration 1.46, 95% confidence interval 1.17-1.83).

CONCLUSION

In this analysis, FullCPR was associated with higher survival compared to CConly. Guidelines should continue to emphasise the importance of compressions and ventilations during resuscitation for patients who suffer OHCA and CPR courses should continue to teach both.