Modifiable factors associated with improved cardiac arrest survival in a multicenter basic life support/defibrillation system: OPALS Study Phase I results. Ontario Prehospital Advanced Life Support

Recruiting Medical, Dental, and Biomedical Students as First Responders in the Immediate Aftermath of the COVID-19 Pandemic: Prospective Follow-Up Study

Background

Basic life support improves survival prognosis after out-of-hospital cardiac arrest, but is too rarely provided before the arrival of professional rescue services. First responder networks have been developed in many regions of the world to decrease the delay between collapse and initiation of resuscitation maneuvers. Their efficiency depends on the number of first responders available and many networks lack potential rescuers. Medical, dental, and biomedical students represent an almost untapped source of potential first responders, and a first study, carried out during the COVID-19 pandemic, led to the recruitment of many of these future professionals even though many restrictions were still in effect.

Objective

The objective of this study was to determine the impact of an enhanced strategy on the recruitment of medical, dental, and biomedical students as first responders in the immediate aftermath of the COVID-19 pandemic.

Methods

This was a prospective follow-up study, conducted between November 2021 and March 2022 at the University of Geneva Faculty of Medicine, Geneva, Switzerland. A web-based study platform was used to manage consent, registrations, and certificates. A first motivational intervention was held early in the academic year and targeted all first-year medical, dental, and biomedical students. Participants first answered a questionnaire designed to assess their initial basic life support knowledge before following an e-learning module. Those who completed the module were able to register for a face-to-face training session held by senior medical students. A course certificate was awarded to those who completed these sessions, enabling them to register as first responders on the Save a Life first responder network. Since the number of students who had enlisted as first responders 2 months after the motivational intervention was markedly lower than expected, a second, unplanned motivational intervention was held in an attempt to recruit more students.

Results

Out of a total of 674 first-year students, 19 (2.5%) students had registered as first responders after the first motivational intervention. This was significantly less than the proportion achieved through the initial study (48/529, 9.1%; P<.001). The second motivational intervention led to the enrollment of 7 more students (26/674, 3.9%), a figure still significantly lower than that of the original study (P<.001). At the end of the study, 76 (11.3%) students had been awarded a certificate of competence.

Conclusions

Contrary to expectations, an earlier presentation during the academic year outside the COVID restriction period did not increase the recruitment of medical, dental, and biomedical students as first responders in the immediate aftermath of the COVID-19 pandemic. The reasons underlying this drop in motivation should be explored to enable the design of focused motivational interventions.

The link between initial cardiac rhythm and survival outcomes in in-hospital cardiac arrest using propensity score matching, adjustment, and weighting

The association between the initial cardiac rhythm and short-term survival in patients with in-hospital cardiac arrest (IHCA) has not been extensively studied despite the fact that it is thought to be a prognostic factor in patients with out-of-hospital cardiac arrest. This study aimed to look at the relationship between initial shockable rhythm and survival to hospital discharge in individuals with IHCA. 1516 adults with IHCA who received chest compressions lasting at least two minutes at the National Taiwan University Hospital between 2006 and 2014 made up the study population. Propensity scores were estimated using a fitted multivariate logistic regression model. Various statistical methodologies were employed to investigate the association between shockable rhythm and the probability of survival to discharge in patients experiencing IHCA, including multivariate adjustment, propensity score adjustment, propensity score matching, and logistic regression based on propensity score weighting. In the original cohort, the multivariate-adjusted odds ratio (OR) was 2.312 (95% confidence interval [CI]: 1.515-3.531, P < 0.001). In additional propensity score adjustment, the OR between shockable rhythm and the probability of survival to hospital discharge in IHCA patients was 2.282 (95% CI: 1.486, 3.504, P < 0.001). The multivariate-adjusted logistic regression model analysis revealed that patients with shockable rhythm had a 1.761-fold higher likelihood of surviving to hospital release in the propensity score-matched cohort (OR = 2.761, 95% CI: 1.084-7.028, P = 0.033). The multivariate-adjusted OR of the inverse probability for the treatment-weighted cohort was 1.901 (95% CI: 1.507-2.397, P < 0.001), and the standardized mortality ratio-weighted cohort was 2.692 (95% CI: 1.511-4.795, P < 0.001). In patients with in-hospital cardiac arrest, Initial cardiac rhythm is an independent predictor of survival to hospital discharge. Depending on various statistical methods, patients with IHCA who have a shockable rhythm have a one to two fold higher probability of survival to discharge than those who have a non-shockable rhythm. This provides a reference for optimizing resuscitation decisions for IHCA patients and facilitating clinical communication.

Challenges & barriers for real-time integration of drones in emergency cardiac care: Lessons from the United States, Sweden, & Canada

Importance

Out-of-hospital cardiac arrest (OHCA) is a leading cause of morbidity and mortality in the US and Europe (∼600,000 incident events annually) and around the world (∼3.8 million). With every minute that passes without cardiopulmonary resuscitation or defibrillation, the probability of survival decreases by 10%. Preliminary studies suggest that uncrewed aircraft systems, also known as drones, can deliver automated external defibrillators (AEDs) to OHCA victims faster than ground transport and potentially save lives.

Objective

To date, the United States (US), Sweden, and Canada have made significant contributions to the knowledge base regarding AED-equipped drones. The purpose of this Special Communication is to explore the challenges and facilitators impacting the progress of AED-equipped drone integration into emergency medicine research and applications in the US, Sweden, and Canada. We also explore opportunities to propel this innovative and important research forward.

Evidence review

In this narrative review, we summarize the AED-drone research to date from the US, Sweden, and Canada, including the first drone-assisted delivery of an AED to an OHCA. Further, we compare the research environment, emergency medical systems, and aviation regulatory environment in each country as they apply to OHCA, AEDs, and drones. Finally, we provide recommendations for advancing research and implementation of AED-drone technology into emergency care.

Findings

The rates that drone technologies have been integrated into both research and real-life emergency care in each country varies considerably. Based on current research, there is significant potential in incorporating AED-equipped drones into the chain of survival for OHCA emergency response. Comparing the different environments and systems in each country revealed ways that each can serve as a facilitator or barrier to future AED-drone research.

Conclusions and relevance

The US, Sweden, and Canada each offers different challenges and opportunities in this field of research. Together, the international community can learn from one another to optimize integration of AED-equipped drones into emergency systems of care.

Temporal elevation of blood pressure is associated with increased risk of sudden cardiac arrest

Hypertension is a known risk factor for sudden cardiac arrest (SCA). However, the role of temporal changes in blood pressure on the risk of SCA is not fully understood. This study was conducted to determine whether a temporal increase or decrease in blood pressure is associated with the risk of SCA. This study was based on nationwide healthcare insurance data. Individuals who underwent nationwide health check-ups in 2009 and 2011 were analyzed. A total of 2,801,153 individuals were evaluated for 8100 SCA events during the 17, 740, 420 person-years of follow-up. In a multivariate analysis, there were linear association between the degree of temporal elevation of systolic blood pressure (SBP) and the risk of SCA: (i) adjusted-hazard ratio (HR) 1.11 (p = 0.001) in 10 ≤ ΔSBP < 20 (mmHg) group; (ii) adjusted-HR 1.40 (p < 0.001) in 20 ≤ ΔSBP < 40 group; and (iii) adjusted-HR 1.88 (p < 0.001) in 40 ≤ ΔSBP group as compared with the reference group (- 10 ≤ ΔSBP < 10). Temporal increase in diastolic blood pressure (DBP) also a showed significant association with SCA risk with the highest risk observed in ∆DBP ≥ 25 group (adjusted-HR 1.61; p < 0.001) as compared with the reference group (- 5 ≤ ΔDBP < 5). The association between SBP and SCA was not affected by age, sex, presence of diabetes mellitus, or baseline SBP. In conclusion, a temporal increase in blood pressure was significantly associated with the occurrence of SCA, and this association was consistent across all subgroups. However, a temporary decrease in blood pressure does not reduce the risk of SCA. Prevention of elevated blood pressure may play an important role in preventing SCA.

FedScore: A privacy-preserving framework for federated scoring system development

OBJECTIVE

We propose FedScore, a privacy-preserving federated learning framework for scoring system generation across multiple sites to facilitate cross-institutional collaborations.

MATERIALS AND METHODS

The FedScore framework includes five modules: federated variable ranking, federated variable transformation, federated score derivation, federated model selection and federated model evaluation. To illustrate usage and assess FedScore's performance, we built a hypothetical global scoring system for mortality prediction within 30 days after a visit to an emergency department using 10 simulated sites divided from a tertiary hospital in Singapore. We employed a pre-existing score generator to construct 10 local scoring systems independently at each site and we also developed a scoring system using centralized data for comparison.

RESULTS

We compared the acquired FedScore model's performance with that of other scoring models using the receiver operating characteristic (ROC) analysis. The FedScore model achieved an average area under the curve (AUC) value of 0.763 across all sites, with a standard deviation (SD) of 0.020. We also calculated the average AUC values and SDs for each local model, and the FedScore model showed promising accuracy and stability with a high average AUC value which was closest to the one of the pooled model and SD which was lower than that of most local models.

CONCLUSION

This study demonstrates that FedScore is a privacy-preserving scoring system generator with potentially good generalizability.

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.

Long-term increase in fasting blood glucose is associated with increased risk of sudden cardiac arrest

BACKGROUND

Diabetes mellitus (DM) is associated with various cardiovascular complications, including sudden cardiac arrest (SCA). Furthermore, the severity of DM, as assessed by fasting blood glucose (FBG), is associated with the risk of SCA. However, whether long-term changes in FBG influence on SCA risk remains to be determined.

METHODS

This study used sequential nationwide health screening data from 2009 and 2011. FBG was measured at each health screening, and ΔFBG was calculated as FBG in 2011-FBG in 2009.

RESULTS

Overall, 2,801,153 people were analyzed, and the mean follow-up duration was 6.33 years. Compared with the euglycemic group (- 20 ≤ ΔFBG < 20), the 20 ≤ ΔFBG < 40, 40 ≤ ΔFBG < 100, and ΔFBG ≥ 100 groups had increased SCA risks of 25% (adjusted hazard ratio [HR] = 1.25; 95% confidence interval [CI] 1.16-1.35; p < 0.001), 66% (adjusted HR = 1.66; 95% CI 1.49-1.86; p < 0.001), and 2.9-fold (adjusted HR = 2.85; 95% CI 2.37-3.44; p < 0.001), respectively. The association between ΔFBG and SCA was maintained in people with DM but not in people without DM. However, sex, age, blood pressure, and presence of heart failure did not affect the association between ΔFBG and SCA. A decrease in ΔFBG over time was not associated with reduced risk of SCA: the adjusted HR was 1.11 (95% CI 0.98-1.27; p = 0.113) for the ΔFBG < -40 group and 1.12 (95% CI 1.03-1.22; p = 0.009) for the - 40 ≤ ∆FBG < - 20 group.

CONCLUSIONS

A long-term increase in ΔFBG can be associated with increased risk of SCA in people with DM. However, a long-term decrease in ΔFBG was not associated with reduced risk of SCA. Actions to prevent increase in FBG can have significant effects on public health in terms of SCA prevention.

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.

Initial rhythm and survival in refractory out-of-hospital cardiac arrest. Post-hoc analysis of the Prague OHCA randomized trial

BACKGROUND

The prognosis of refractory out-of-hospital cardiac arrest (OHCA) is generally poor. A recent Prague OHCA study has demonstrated that an invasive approach (including extracorporeal cardiopulmonary resuscitation, ECPR) is a feasible and effective treatment strategy in refractory OHCA. Here we present a post-hoc analysis of the role of initial rhythm on patient outcomes.

METHODS

The study enrolled patients who had a witnessed OHCA of presumed cardiac cause without early recovery of spontaneous circulation. The initial rhythm was classified as either a shockable or a non-shockable rhythm. The primary outcome was a composite of 180 day-survival with Cerebral Performance in Category 1 or 2.

RESULTS

256 (median age 58y, 17% females) patients were enrolled. The median (IQR) duration of resuscitation was 52 (33-68) minutes. 156 (61%) and 100 (39%) of patients manifested a shockable and non-shockable rhythm, respectively. The primary outcome was achieved in 63 (40%) patients with a shockable rhythm and in 5 (5%) patients with a non-shockable rhythm (p < 0.001). When patients were analyzed separately based on whether the treatment was invasive (n = 124) or standard (n = 132), the difference in the primary endpoint between shockable and non-shockable initial rhythms remained significant (35/72 (49%) vs 4/52 (8%) in the invasive arm and 28/84 (33%) vs 1/48 (2%) in the standard arm; p < 0.001).

CONCLUSION

An initial shockable rhythm and treatment with an invasive approach is associated with a reasonable neurologically favorable survival for 180 days despite refractory OHCA. Non-shockable initial rhythms bear a poor prognosis in refractory OHCA even when ECPR is readily available.

At odds: How intraprofessional conflict and stratification has stalled the Ontario paramedic professionalization project

Historically, self-regulation has provided some professions with power and market control. Currently, however, governments have scrutinized this approach, and priorities have shifted toward other mandates. This study examines the case of paramedics in Ontario, Canada, where self-regulation is still the dominant regulatory model for the healthcare professions but not for paramedics. Instead, paramedics in Ontario are co-regulated by government and physician-directed groups, with paramedics subordinate to both. This paper, which draws on interviews with paramedic industry leaders analyzed through the lens of institutional work, examines perspectives on the relevance of self-regulation to the paramedic professionalization project. Participants had varying views on the importance of self-regulation in obtaining professional status, with some rejecting its role in professionalization and others embracing regulatory reform. Because paramedics disagree on what being a profession means, the collective professionalization project has stalled. This research has implications for understanding the impact of intraprofessional relationships and conflict on professionalization projects.

Bystander-witnessed cardiopulmonary resuscitation by nonfamily is associated with neurologically favorable survival after out-of-hospital cardiac arrest in Miyazaki City District

BACKGROUND

Bystander intervention in cases of out-of-hospital cardiac arrest (OHCA) is a key factor in bridging the gap between the event and the arrival of emergency health services at the site. This study investigated the implementation rate of bystander cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) and 1-month survival after OHCA in Miyazaki prefecture and Miyazaki city district as well as compared them with those of eight prefectures in the Kyushu-Okinawa region in Japan. In addition, we analyzed prehospital factors associated with survival outcomes in Miyazaki city district.

METHODS

We used data from an annual report released by the Fire and Disaster Management Agency of Japan (n = 627,982) and the Utstein reporting database in Miyazaki city district (n = 1,686) from 2015 to 2019.

RESULT

Despite having the highest rate of bystander CPR (20.8%), the 1-month survival rate (15.7%) of witnessed OHCA cases of cardiac causes in Miyazaki city district was comparable with that in the eight prefectures between 2015 and 2019. However, rates of survival (10.7%) in Miyazaki prefecture were lower than those in other prefectures. In 1,686 patients with OHCA (74 ± 18 years old, 59% male) from the Utstein reporting database identical to the 5-year study period in Miyazaki city district, binary logistic regression analysis demonstrated that age of the recipient [odds ratio (OR) 0.979, 95% confidential interval (CI) 0.964-0.993, p = 0.004)], witness of the arrest event (OR 7.501, 95% CI 3.229-17.428, p < 0.001), AED implementation (OR 14.852, 95% CI 4.226-52.201, p < 0.001), and return of spontaneous circulation (ROSC) before transport (OR 31.070, 95% CI 16.585-58.208, p < 0.001) predicted the 1-month survival with favorable neurological outcomes. In addition, chest compression at a public place (p < 0.001) and by nonfamily members (p < 0.001) were associated with favorable outcomes (p = 0.015).

CONCLUSIONS

We found differences in 1-month survival rates after OHCA in the Kyushu-Okinawa region of Japan. Our results suggest that on-field ROSC with defibrillation performed by nonfamily bystanders who witnessed the event determines 1-month neurological outcomes after OHCA in Miyazaki city district. Continued education of citizens on CPR techniques and better access to AED devices may improve outcomes.

Long-Term Outcomes after Non-Traumatic Out-of-Hospital Cardiac Arrest in Pediatric Patients: A Systematic Review

Long-term outcomes after non-traumatic pediatric out-of-hospital cardiac arrest (OHCA) are not well understood. This systematic review aimed to summarize long-term outcomes (1 year and beyond), including overall survival, survival with favorable neurological outcomes, and health-related quality of life (HRQoL) outcomes) amongst pediatric OHCA patients who survived to discharge. Embase, Medline, and The Cochrane Library were searched from inception to October 6, 2021. Studies were included if they reported outcomes at 1 year or beyond after pediatric OHCA. Data abstraction and quality assessment was conducted by three authors independently. Qualitative outcomes were reported systematically. Seven studies were included, and amongst patients that survived to hospital discharge or to 30 days, longer-term survival was at least 95% at 24 months of follow up. A highly variable proportion (range 10–71%) of patients had favorable neurological outcomes at 24 months of follow up. With regard to health-related quality of life outcomes, at a time point distal to 1 year, at least 60% of pediatric non-traumatic OHCA patients were reported to have good outcomes. Our study found that at least 95% of pediatric OHCA patients, who survived to discharge, survived to a time point distal to 1 year. There is a general paucity of data surrounding the pediatric OHCA population.

A Short Intervention and an Interactive E-Learning Module to Motivate Medical and Dental Students to Enlist as First Responders: Implementation Study (Preprint)

Background

Prompt and proficient basic life support (BLS) maneuvers are essential to increasing the odds of survival after out-of-hospital cardiac arrest. However, significant time can elapse before the arrival of professional rescuers. To decrease these delays, many countries have developed first responder networks. These networks are composed of BLS-certified lay or professional rescuers who can be dispatched by emergency medical communication centers to take care of those who experience out-of-hospital cardiac arrest. Many systems are, however, limited by a relatively low number of active first responders, and first-year medical and dental students may represent an almost untapped pool of potential rescuers. On top of providing an enhanced BLS coverage to the population, this could also help medical students be better prepared to their future role as certified health care providers and address societal expectations regarding health care students.

Objective

Our objective was to describe the impact of a short motivational intervention followed by a blended BLS course (e-learning and practice session) designed to motivate first-year medical and dental students to enlist as first responders.

Methods

A short, web-based, motivational intervention presenting this project took place, and first-year University of Geneva, Faculty of Medicine students were provided with a link to the study platform. Those who agreed to participate were redirected to a demographic questionnaire before registering on the platform. The participants were then asked to answer a second questionnaire designed to determine their baseline knowledge prior to following an interactive e-learning module. Upon completion, a web-based booking form enabling them to register for a 1-hour practice session was displayed. These sessions were held by senior medical students who had been trained and certified as BLS instructors. The participants who attended these practice sessions were asked to answer a postcourse questionnaire before receiving the certificate enabling them to register as first responders.

Results

Out of the 529 first-year students registered at University of Geneva, Faculty of Medicine on January 14, 2021, 190 (35.9%) initially agreed to participate. Moreover, 102 (19.3%) attended the practice sessions, and 48 (9.1%) had completed all training and enlisted as first responders on the dedicated platform, Save a Life, at 6 months (July 14, 2021). Postcourse confidence in resuscitation skills was associated with a higher likelihood of registering as first responder (P=.03). No association was found between prior BLS knowledge and the probability of registering to a practice session (P=.59), of obtaining a course completion certificate (P=.29), or of enlisting as first responder (P=.56).

Conclusions

This study shows that a motivational intervention associated with a short BLS course can convince medical students to enlist as first responders. Further studies are needed to understand the rather low proportion of medical students finally registering as first responders.

International Registered Report Identifier (IRRID)

RR2-10.2196/24664

Moderating effects of out-of-hospital cardiac arrest characteristics on the association between EMS response time and survival

BACKGROUND

Although several Utstein variables are known to independently improve survival, how they moderate the effect of emergency medical service (EMS) response times on survival is unknown.

OBJECTIVES

To quantify how public location, witnessed status, bystander CPR, and bystander AED shock individually and jointly moderate the effect of EMS response time delays on OHCA survival.

METHODS

This retrospective cohort study was a secondary analysis of the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest database (December 2005 to June 2015). We included all adult, non-traumatic, non-EMS witnessed, and EMS-treated OHCAs from eleven sites across the US and Canada. We trained a logistic regression model with standard Utstein control variables and interaction terms between EMS response time and the four aforementioned OHCA characteristics.

RESULTS

102,216 patients were included. Three of the four characteristics - witnessed OHCAs (OR = 0.962), bystander CPR (OR = 0.968) and public location (OR = 0.980) - increased the negative effect of a one-minute delay on the odds of survival. In contrast, a bystander AED shock decreased the negative effect of a one-minute response time delay on the odds of survival (OR = 1.064). The magnitude of the effect of a one-minute delay in EMS response time on the odds of survival ranged from 1.3% to 9.8% (average: 5.3%), depending on the underlying OHCA characteristics.

CONCLUSIONS

Delays in EMS response time had the largest reduction in survival odds for OHCAs that did not receive a bystander AED shock but were witnessed, occurred in public, and/or received bystander CPR. A bystander AED shock appears to be protective against a delay in EMS response time.

Early recognition of a caller's emotion in out-of-hospital cardiac arrest dispatching: An artificial intelligence approach

AIM

This study aimed to develop an AI model for detecting a caller's emotional state during out-of-hospital cardiac arrest calls by processing audio recordings of dispatch communications.

METHODS

Audio recordings of 337 out-of-hospital cardiac arrest calls from March-April 2011 were retrieved. The callers' emotional state was classified based on the emotional content and cooperative scores. Mel-frequency cepstral coefficients extracted essential information from the voice signals. A support vector machine was utilised for the automatic judgement, and repeated random sub-sampling cross validation (RRS-CV) was applied to evaluate robustness. The results from the artificial intelligence classifier were compared with the consensus of expert reviewers.

RESULTS

The audio recordings were classified into five emotional content and cooperative score levels. The proposed model had an average positive predictive value of 72.97%, a negative predictive value of 93.47%, sensitivity of 38.76%, and specificity of 98.29%. If only the first 10 seconds of the recordings were considered, it had an average positive predictive value of 84.62%, a negative predictive value of 93.57%, sensitivity of 52.38%, and specificity of 98.64%. The artificial intelligence model's performance maintained preferable results for emotionally stable cases.

CONCLUSION

Artificial intelligence models can possibly facilitate the judgement of callers' emotional states during dispatch conversations. This model has the potential to be utilised in practice, by pre-screening emotionally stable callers, thus allowing dispatchers to focus on cases that are judged to be emotionally unstable. Further research and validation are required to improve the model's performance and make it suitable for the general population.

Towards individualised treatment of out-of-hospital cardiac arrest patients: an update on technical innovations in the prehospital chain of survival

Out-of-hospital cardiac arrest (OHCA) is a major healthcare problem, with approximately 200 weekly cases in the Netherlands. Its critical, time-dependent nature makes it a unique medical situation, of which outcomes strongly rely on infrastructural factors and on-scene care by emergency medical services (EMS). Survival to hospital discharge is poor, although it has substantially improved, to roughly 25% over the last years. Recognised key factors, such as bystander resuscitation and automated external defibrillator use at the scene, have been markedly optimised with the introduction of technological innovations. In an era with ubiquitous smartphone use, the Dutch digital text message alert platform HartslagNu (www.hartslagnu.nl) increasingly contributes to timely care for OHCA victims. Guidelines emphasise the role of cardiac arrest recognition and early high-quality bystander resuscitation, which calls for education and improved registration at HartslagNu. As for EMS care, new technological developments with future potential are the selective use of mechanical chest compression devices and extracorporeal life support. As a future innovation, ‘smart’ defibrillators are under investigation, guiding resuscitative interventions based on ventricular fibrillation waveform characteristics. Taken together, optimisation of available prehospital technologies is crucial to further improve OHCA outcomes, with particular focus on more available trained volunteers in the first phase and additional research on advanced EMS care in the second phase.

An Eastern Association for the Surgery of Trauma multicenter trial examining prehospital procedures in penetrating trauma patients

BACKGROUND

Prehospital procedures (PHP) by emergency medical services (EMS) are performed regularly in penetrating trauma patients despite previous studies demonstrating no benefit. We sought to examine the influence of PHPs on outcomes in penetrating trauma patients in urban locations where transport to trauma center is not prolonged. We hypothesized that patients without PHPs would have better outcomes than those undergoing PHP.

METHODS

This was an Eastern Association for the Surgery of Trauma-sponsored, multicenter, prospective, observational trial of adults (18+ years) with penetrating trauma to the torso and/or proximal extremity presenting at 25 urban trauma centers. The impact of PHPs and transport mechanism on in-hospital mortality were examined.

RESULTS

Of 2,284 patients included, 1,386 (60.7%) underwent PHP. The patients were primarily Black (n = 1,527, 66.9%) males (n = 1,986, 87.5%) injured by gunshot wound (n = 1,510, 66.0%) with 34.1% (n = 726) having New Injury Severity Score of ≥16. A total of 1,427 patients (62.5%) were transported by Advanced Life Support EMS, 17.2% (n = 392) by private vehicle, 13.7% (n = 312) by police, and 6.7% (n = 153) by Basic Life Support EMS. Of the PHP patients, 69.1% received PHP on scene, 59.9% received PHP in route, and 29.0% received PHP both on scene and in route. Initial scene vitals differed between groups, but initial emergency department vitals did not. Receipt of ≥1 PHP increased mortality odds (odds ratio [OR], 1.36; 95% confidence interval [CI], 1.01-1.83; p = 0.04). Logistic regression showed increased mortality with each PHP, whether on scene or during transport. Subset analysis of specific PHP revealed that intubation (OR, 10.76; 95% CI, 4.02-28.78; p < 0.001), C-spine immobilization (OR, 5.80; 95% CI, 1.85-18.26; p < 0.01), and pleural decompression (OR, 3.70; 95% CI, 1.33-10.28; p = 0.01) had the highest odds of mortality after adjusting for multiple variables.

CONCLUSION

Prehospital procedures in penetrating trauma patients impart no survival advantage and may be harmful in urban settings, even when performed during transport. Therefore, PHP should be forgone in lieu of immediate transport to improve patient outcomes.

LEVEL OF EVIDENCE

Prognostic, level III.

Outcomes for out-of-hospital cardiac arrest transported to emergency departments in Hanoi, Vietnam: A multi-centre observational study

OBJECTIVE

To describe the outcomes of patients with out-of-hospital cardiac arrest (OHCA) transported to hospital in Hanoi, Vietnam.

METHODS

This was a multi-centre observational study of patients presenting with OHCA to one of five tertiary care hospital EDs in Hanoi from 2017 to 2019.

RESULTS

We analysed data from 239 OHCA cases of which 70.7% were witnessed, and 8.4% received bystander cardiopulmonary resuscitation (CPR). The emergency medical services (EMS) transported 20.5% of cases to hospital with the remaining being transported by private vehicle. No patients received external defibrillation before arriving to hospital. Return of spontaneous circulation in hospital was 33.1%, with 3.8% of patients survived to hospital discharge and only one patient (0.4%) discharged from hospital with a favourable neurological outcome.

CONCLUSIONS

In cases of OHCA in Hanoi, both the proportion of cases receiving bystander CPR and EMS transportation were small. Urgent investments in pre-hospital capacity, training and capabilities are required to improve outcomes for OHCA in Hanoi.

Transportation during and after cardiac arrest: who, when, how and where?

PURPOSE OF REVIEW

Out-of-hospital cardiac arrest (OHCA) is the most devastating and time-critical medical emergency. Survival after OHCA requires an integrated system of care, of which transport by emergency medical services is an integral component. The transport system serves to commence and ensure uninterrupted high-quality resuscitation in suitable patients who would benefit, terminate resuscitation in those that do not, provide critical interventions, as well as convey patients to the next appropriate venue of care. We review recent evidence surrounding contemporary issues in the transport of OHCA, relating to who, where, when and how to transport these patients.

RECENT FINDINGS

We examine the clinical and systems-related evidence behind issues including: contemporary approaches to field termination of resuscitation in patients in whom continued resuscitation and transport to hospital would be medically futile, OHCA patients and organ donation, on-scene versus intra-transport resuscitation, significance of response time, intra-transport interventions (mechanical chest compression, targeted temperature management, ECMO-facilitated cardiopulmonary resuscitation), OHCA in high-rise locations and cardiac arrest centers. We highlight gaps in current knowledge and areas of active research.

SUMMARY

There remains limited evidence to guide some decisions in transporting the OHCA patient. Evidence is urgently needed to elucidate the roles of cardiac arrest centers and ECPR in OHCA.

Early blood pH as an independent predictor of neurological outcome in patients with out-of-hospital cardiac arrest: A retrospective observational study

ABSTRACT

Metabolic acidosis is observed in 98% of patients with out-of-hospital cardiac arrest (OHCA). The longer the no-flow or low-flow duration, the more severe is the acidosis in these patients. This study explored whether blood pH in early stages of advanced life support (ALS) was an independent predictor of neurological prognosis in patients with OHCA.We retrospectively enrolled patients with OHCA from January 2012 to June 2018 in a single-medical tertiary hospital in Taiwan. Patients with OHCA whose blood gas analyses within 5 minutes after receiving ALS at the emergency department (ED) were enrolled. Patients younger than 20 years old, with cardiac arrest resulting from traumatic or circumstantial causes, with return of spontaneous circulation (ROSC) before ED arrival, lacking record of initial blood gas analysis, and with do-not-resuscitate orders were excluded. The primary outcome of this study was neurological status at hospital discharge.In total, 2034 patients with OHCA were enrolled. The majority were male (61.89%), and the average age was 67.8 ± 17.0 years. Witnessed OHCA was noted in 571 cases, cardiopulmonary resuscitation was performed before paramedic arrival in 512 (25.2%) cases, and a shockable rhythm was observed in 269 (13.2%). Blood pH from initial blood gas analysis remained an independent predictor of neurological outcome after multivariate regression.Blood pH at early stages of ALS was an independent prognostic factor of post-OHCA neurological outcome. Blood gas analysis on arrival at the ED may provide additional information about the prognosis of patients with OHCA.

Utility of Glucose Testing and Treatment of Hypoglycemia in Patients with Out-of-Hospital Cardiac Arrest

Objective: Many emergency medical services (EMS) protocols for out-of-hospital cardiac arrests (OHCA) include point-of-care (POC) glucose measurement and administration of dextrose, despite limited knowledge of benefit. The objective of this study was to describe the incidence of hypoglycemia and dextrose administration by EMS in OHCA and subsequent patient outcomes.Methods: This was a retrospective analysis of OHCA in a large, regional EMS system from 2011 to 2017. Patients ≥18 years old with non-traumatic OHCA and attempted field resuscitation by paramedics were included. The primary outcomes were frequency of POC glucose measurement, hypoglycemia (glucose <60 mg/dl), and dextrose/glucagon administration (treatment group). The secondary outcomes included field return of spontaneous circulation (ROSC), survival to hospital discharge (SHD), and survival with good neurologic outcome.Results: There were 46,211 OHCAs during the study period of which 33,851 (73%) had a POC glucose test performed. Glucose levels were documented in 32,780 (97%), of whom 2,335 (7%) were hypoglycemic. Among hypoglycemic patients, 41% (959) received dextrose and/or glucagon. Field ROSC was achieved in 30% (286) of hypoglycemic patients who received treatment. Final outcome was determined for 1,714 (73%) of the hypoglycemic cases, of whom 120 (7%) had SHD and 66 (55%) had a good neurologic outcome. Of the 32,780 patients with a documented POC glucose result who were identified as hypoglycemic, only 27 (0.08%) received field treatment, and survived to discharge with good neurologic outcome. 48 (6%) of patients in the treatment group had SHD vs. 72 (8%) without treatment, risk difference -2.0% (95%CI -4.4%, 0.4%), p = 0.1.Conclusion: In this EMS system, POC glucose testing was common in adult OHCA, yet survival to hospital discharge with good neurologic outcome did not differ between patients treated and untreated for hypoglycemia. These results question the common practice of measuring and treating hypoglycemia in OHCA patients.

Association between Survival and Time of On-Scene Resuscitation in Refractory Out-of-Hospital Cardiac Arrest: A Cross-Sectional Retrospective Study

It is estimated that over 60% of out-of-hospital cardiac arrest (OHCA) patients with a shockable rhythm are refractory to current treatment, never achieve return of spontaneous circulation, or die before they reach the hospital. Therefore, we aimed to identify whether field resuscitation time is associated with survival rate in refractory OHCA (rOHCA) with a shockable initial rhythm. This cross-sectional retrospective study extracted data of emergency medical service (EMS)-treated patients aged ≥ 15 years with OHCA of suspected cardiac etiology and shockable initial rhythm confirmed by EMS providers from the OHCA registry database of Korea. A multivariable logistic regression analysis was conducted for survival to discharge and good neurological outcomes in the scene time interval groups. The median scene time interval for the non-survival and survival to discharge patients were 16 (interquartile range (IQR) 13-21) minutes and 14 (IQR 12-16) minutes, respectively. In this study, for rOHCA patients with a shockable rhythm, continuing CPR for more than 15 min on the scene was associated with a decreased chance of survival and good neurological outcome. In particular, we found that in the patients whose transport time interval was >10 min, the longer scene time interval was negatively associated with the neurological outcome.

Defibrillator charging before rhythm analysis causes peri-shock pauses exceeding guideline recommended maximum 5 s : A randomized simulation trial

INTRODUCTION

Charging defibrillators prior to analyzing heart rhythms may decrease the no-flow time during rhythm check pauses while resuscitating in cardiac arrest. Although this anticipatory method is already used in some centers little is known about its safety. This study was carried out to confirm the safety and feasibility of the anticipatory method. It was hypothesized that this anticipatory method results in shorter total no-flow times, while other parameters of defibrillation efficacy including defibrillator safety and minimization of peri-shock pauses are unchanged.

METHODS

This manikin study assigned 243 medical students randomly to study groups, 121 to the anticipatory method and 122 to the recommended European Resuscitation Council (ERC) algorithm. Of these 237 students ultimately underwent training (112 anticipatory method vs. 125 ERC algorithm). Participants were assessed and video recorded during a simulated cardiac arrest scenario which included three different heart rhythms (ventricular fibrillation [VF], pulseless ventricular tachycardia [pVT], asystole) in randomized order. Video and software analyses were performed. Defibrillation safety was assessed using a 17-item checklist defined beforehand.

RESULTS

A total of 203 simulated cardiac arrests (75 anticipatory method and 128 ERC 2010 algorithm) were analyzed. The anticipatory method did not significantly reduce no-flow time (25.8 s, standard deviation, SD 7.4 s vs. 27.4 s SD 8.4 s, p = 0.19); however, peri-shock pauses were significantly longer in the anticipatory group compared to the ERC 2010 group (9.5 s SD 2.8 s vs. 3.3 s SD 1.9 s, p < 0.001). No significant difference concerning defibrillation safety between the groups was observed according to the 17-item checklist (14.6 SD 1.6 vs. 15.0 SD 1.4, p = 0.07).

CONCLUSION

Charging defibrillators before rhythm analysis did not decrease total no-flow time in simulated cardiac arrests but resulted in significantly longer peri-shock pauses exceeding 5 s. No significant differences in defibrillation safety were observed between the groups.

Implementation of a National 5-Year Plan for Prehospital Emergency Care in Singapore and Impact on Out-of-Hospital Cardiac Arrest Outcomes From 2011 to 2016

Background

Outcomes of patients from out‐of‐hospital cardiac arrest (OHCA) vary widely globally because of differences in prehospital systems of emergency care. National efforts had gone into improving OHCA outcomes in Singapore in recent years including community and prehospital initiatives. We aimed to document the impact of implementation of a national 5‐year Plan for prehospital emergency care in Singapore on OHCA outcomes from 2011 to 2016.

Methods and Results

Prospective, population‐based data of OHCA brought to Emergency Departments were obtained from the Pan‐Asian Resuscitation Outcomes Study cohort. The primary outcome was Utstein (bystander witnessed, shockable rhythm) survival‐to‐discharge or 30‐day postarrest. Mid‐year population estimates were used to calculate age‐standardized incidence. Multivariable logistic regression was performed to identify prehospital characteristics associated with survival‐to‐discharge across time. A total of 11 465 cases qualified for analysis. Age‐standardized incidence increased from 26.1 per 100 000 in 2011 to 39.2 per 100 000 in 2016. From 2011 to 2016, Utstein survival rates nearly doubled from 11.6% to 23.1% (P=0.006). Overall survival rates improved from 3.6% to 6.5% (P<0.001). Bystander cardiopulmonary resuscitation rates more than doubled from 21.9% to 56.3% and bystander automated external defibrillation rates also increased from 1.8% to 4.6%. Age ≤65 years, nonresidential location, witnessed arrest, shockable rhythm, bystander automated external defibrillation, and year 2016 were independently associated with improved survival.

Conclusions

Implementation of a national prehospital strategy doubled OHCA survival in Singapore from 2011 to 2016, along with corresponding increases in bystander cardiopulmonary resuscitation and bystander automated external defibrillation. This can be an implementation model for other systems trying to improve OHCA outcomes.

Enhancing citizens response to out-of-hospital cardiac arrest: A systematic review of mobile-phone systems to alert citizens as first responders

INTRODUCTION

Involving laypersons in response to out-of-hospital cardiac arrest through mobile-phone technology is becoming widespread in numerous countries, and different solutions were developed. We performed a systematic review on the impact of alerting citizens as first responders and to provide an overview of different strategies and technologies used.

METHODS

We searched electronic databases up to October 2019. Eligible studies described systems to alert citizens first responders to out-of-hospital cardiac arrest through text messages or apps. We analyzed the implementation and performance of these systems and their impact on patients' outcomes.

RESULTS

We included 28 manuscripts describing 12 different systems. The first text message system was implemented in 2006 and the first app in 2010. First responders accepted to intervene in median (interquartile) 28.7% (27-29%) of alerts and reached the scene after 4.6 (4.4-5.5) minutes for performing CPR. First responders arrived before ambulance, started CPR and attached a defibrillator in 47% (34-58%), 24% (23-27%) and 9% (6-14%) of cases, respectively. Pooled analysis showed that first responders activation increased layperson-CPR rates (1463/2292 [63.8%] in the intervention group vs. 1094/1989 [55.0%] in the control group; OR = 1.70; 95% CI, 1.11-2.60; p = 0.01) and survival to hospital discharge or at 30 days (327/2273 [14.4%] vs. 184/1955 [9.4%]; OR = 1.51; 95% CI, 1.24-1.84; p < 0.001).

CONCLUSIONS

Alerting citizens as first responders in case of out-of-hospital cardiac arrest may reduce the intervention-free time and improve patients' outcomes.

Patient and Institutional Characteristics Influence the Decision to Use Extracorporeal Cardiopulmonary Resuscitation for In-Hospital Cardiac Arrest

BACKGROUND

Outcomes from extracorporeal cardiopulmonary resuscitation (ECPR) are felt to be influenced by selective use, but the characteristics of those receiving ECPR are undefined. We demonstrate the relationship between individual patient and hospital characteristics and the probability of ECPR use.

METHODS AND RESULTS

We performed an observational analysis of adult inpatient cardiac arrests in the United States from 2000 to 2018 reported to the American Heart Association's Get With The Guidelines—Resuscitation registry restricted to hospitals that provided ECPR. We calculated case mix adjusted relative risk (RR) of receiving ECPR for individual characteristics. From 2000 to 2018, 129 736 patients had a cardiac arrest (128 654 conventional cardiopulmonary resuscitation and 1082 ECPR) in 224 hospitals that offered ECPR. ECPR use was associated with younger age (RR, 1.5 for <40 vs. 40–59 years; 95% CI, 1.2–1.8), no pre‐existing comorbidities (RR, 1.4; 95% CI, 1.1–1.8) or cardiac‐specific comorbidities (congestive heart failure [RR, 1.3; 95% CI, 1.2–1.5], prior myocardial infarction [RR, 1.4; 95% CI, 1.2–1.6], or current myocardial infarction [RR, 1.5; 95% CI, 1.3–1.8]), and in locations of procedural areas at the times of cardiac arrest (RR, 12.0; 95% CI, 9.5–15.1). ECPR decreased after hours (3–11 pm [RR, 0.8; 95% CI, 0.7–1.0] and 11 pm–7 am [RR, 0.6; 95% CI, 0.5–0.7]) and on weekends (RR, 0.7; 95% CI, 0.6–0.9).

CONCLUSIONS

Less than 1% of in‐hospital cardiac arrest patients are treated with ECPR. ECPR use is influenced by patient age, comorbidities, and hospital system factors. Randomized controlled trials are needed to better define the patients in whom ECPR may provide a benefit.

Indicators Related to Cardiopulmonary Resuscitation According to Occupation Among Family Members of Coronary Heart Disease Patients

This study aimed to evaluate differences in cardiopulmonary resuscitation (CPR)-related indicators among families of community-dwelling coronary heart disease (CHD) patients according to their occupation. A total of 6,867 family members living with CHD patients were selected for analysis from the 2016 Korea Community Health Survey. Respondents' occupations were classified into managers and professionals (MP), clerks (CL), service and sales workers (SSW), agricultural/forestry/fishery workers (AFFW), mechanical and manual laborers (MML), and homemakers and unemployed (HU). The adjusted odds ratio (aOR) for awareness of CPR in the MP (3.82), SSW (1.73), and MML (1.29) groups were higher than that in HU (reference), while the CL (1.42) and AFFW (1.04) groups showed no significant difference compared to HU. The aORs for experience with CPR education and manikin-assisted CPR training were higher among the MP (4.00 and 3.94), CL (2.61 and 2.26), SSW (2.02 and 1.91), and MML (1.99 and 1.69) groups than in HU, and only AFFW (1.22 and 1.18) showed no difference from HU. Finally, the aOR for self-efficacy in CPR performance was significantly higher among the MP (3.17), CL (1.64), SSW (1.87), and MML (1.44) groups than in HU. However, there was no significant difference between AFFW (1.22) and HU in self-efficacy in CPR performance. To improve the survival rate of CHD patients through successful CPR at the pre-hospital stage during cardiac arrest, it is important to increase the ability of family members of CHD patients to perform CPR, especially among those in AFFW and HU occupations.

Management of Out-of-Hospital Cardiac Arrest Complicating Acute Coronary Syndromes

PURPOSE OF THE REVIEW

Out-of-hospital cardiac arrest (OHCA) complicating acute coronary syndromes (ACS) continues to carry a high rate of morbidity and mortality despite significant advances in EMS and interventional cardiology services. In this review, we discuss an evidence-based approach to the initial care and management of patients with OHCA complicating ACS from the pre-hospital response and initial resuscitation strategy, to advanced therapies such as coronary angiography, targeted-temperature management, neuro-prognostication, and care of the post-arrest patient.

RECENT FINDINGS

Early recognition of cardiac arrest and prompt initiation of bystander CPR are the most important factors associated with improved survival. A comprehensive and coordinated approach to in-hospital management, including PCI, targeted temperature management, critical care, and hemodynamic support represents a significant critical link in the chain of survival. OHCA complicated by ACS continues to be one of the most challenging disease states facing healthcare practitioners and maintains a high mortality rate despite substantial advancements in healthcare delivery. A comprehensive approach to in-hospital management and further exploration of novel interventions, including ECMO, may yield opportunities to optimize care and improve outcomes for cardiac arrest patients.

Effectiveness of a community based out-of-hospital cardiac arrest (OHCA) interventional bundle: Results of a pilot study

BACKGROUND

70% of Out-of-hospital cardiac arrests (OHCA) in Singapore occur in residential areas, and are associated with poorer outcomes. We hypothesized that an interventional bundle consisting of Save-A-life (SAL) initiative (cardiopulmonary resuscitation (CPR)/automated external defibrillator (AED) training and public-housing AED installation), dispatcher-assisted CPR (DA-CPR) program and myResponder (mobile application) will improve OHCA survival.

METHODS

This is pilot data from initial implementation of a stepped-wedge, before-after, real-world interventional bundle in six selected regions. Under the SAL initiative, 30,000 individuals were CPR/AED trained, with 360 AEDs installed. Data was obtained from Singapore's national OHCA Registry. We included all adult patients who experienced OHCA in Singapore from 2011 to 2016 within study regions, excluding EMS-witnessed cases and cases due to trauma/drowning/ electrocution. Cases occurring before and after intervention were allocated as control and intervention groups respectively. Survival was assessed via multivariable logistic regression.

RESULTS

1241 patients were included for analysis (Intervention: 361; Control: 880). The intervention group had higher mean age (70 vs 67 years), survival (3.3% [12/361] vs. 2.2% [19/880]), pre-hospital return of spontaneous circulation (ROSC) (9.1% [33/361] vs 5.1% [45/880]), bystander CPR (63.7% [230/361] vs 44.8% [394/880]) and bystander AED application (2.8% [10/361] vs 1.1% [10/880]). After adjusting for age, gender, race and significant covariates, the intervention was associated with increased odds ratio (OR) for survival (OR 2.39 [1.02-5.62]), pre-hospital ROSC (OR 1.94 [1.15-3.25]) and bystander CPR (OR 2.29 [1.77-2.96]).

CONCLUSION

The OHCA interventional bundle (SAL initiative, DA-CPR, myResponder) significantly improved survival and is being scaled up as a national program.

Recent advances in personalizing cardiac arrest resuscitation

Cardiac arrest remains a significant cause of death and disability throughout the world. However, as our understanding of cardiac arrest and resuscitation physiology has developed, new technologies are fundamentally altering our potential to improve survival and neurologic sequela. Some advances are relatively simple, requiring only alterations in current basic life support measures or integration with pre-hospital organization, whereas others, such as extra-corporeal membrane oxygenation, require significant time and resource investments. When combined with consistent rescuer and patient-physiologic monitoring, these innovations allow an unprecedented capacity to personalize cardiac arrest resuscitation to patient-specific pathophysiology. However, as more extensive options are established, it can be difficult for providers to incorporate novel resuscitation techniques into a cardiac arrest protocol which can fit a wide variety of cases with varying complexity. This article will explore recent advances in our understanding of cardiac arrest physiology and resuscitation sciences, with particular focus on the metabolic phase after significant ischemia has been induced. To this end, we establish a practical consideration for providers seeking to integrate novel advances in cardiac arrest resuscitation into daily practice.

Derivation and Validation of the SWAP Score for Very Early Prediction of Neurologic Outcome in Patients With Out-of-Hospital Cardiac Arrest

STUDY OBJECTIVE

For patients with out-of-hospital cardiac arrest who receive cardiopulmonary resuscitation in an emergency department (ED), the early evaluation of their neurologic prognosis is essential for emergency physicians. The aim of this study is to establish a simple and useful assessment tool for rapidly estimating the prognosis of patients with out-of-hospital cardiac arrest after their arrival at an ED.

METHODS

A total of 852 patients admitted from January 1, 2015, to June 30, 2017, were prospectively registered and enrolled in the derivation cohort. Multivariate logistic regression on this cohort identified 4 independent factors associated with unfavorable outcomes: initial nonshockable rhythm (odds ratio [OR] 3.40; 95% confidence interval [CI] 1.58 to 7.32), no witness of collapse (OR 3.19; 95% CI 1.51 to 6.75), older than 60 years (OR 3.65; 95% CI 1.64 to 8.09), and pH less than or equal to 7.00 (OR 3.27; 95% CI 1.42 to 7.54). The shockable rhythm-witness-age-pH (SWAP) score was developed and 1 point was assigned to each predictor.

RESULTS

For a SWAP score of 4, the specificity was 97.14% (95% CI 91.62% to 100%) for unfavorable outcomes in the derivation cohort. For validation, we retrospectively collected data for 859 patients with out-of-hospital cardiac arrest from January 1, 2012, to December 31, 2014. A SWAP score of 4 was 100% specific (95% CI 99.9% to 100%) for unfavorable outcomes in the validation cohort.

CONCLUSION

The SWAP score is a simple and useful predictive model that may provide information for the very early estimation of prognosis for patients with out-of-hospital cardiac arrest. Further research is required to integrate ultrasonographic findings and validate the SWAP score's application in other populations.

Survival of patients with and without diabetes following out-of-hospital cardiac arrest: A nationwide Danish study

BACKGROUND

Research regarding out-of-hospital cardiac arrest (OHCA) survival of diabetes patients is sparse and it remains unknown whether initiatives to increase OHCA survival benefit diabetes and non-diabetes patients equally. We therefore examined overall and temporal survival in diabetes and non-diabetes patients following OHCA.

METHODS

Adult presumed cardiac-caused OHCAs were identified from the Danish Cardiac Arrest Registry (2001-2014). Associations between diabetes and return of spontaneous circulation upon hospital arrival and 30-day survival were estimated with logistic regression adjusted for patient- and OHCA-related characteristics.

RESULTS

In total, 28,955 OHCAs were included of which 4276 (14.8%) had diabetes. Compared with non-diabetes patients, diabetes patients had more comorbidities, same prevalence of bystander-witnessed arrests (51.7% vs. 52.7%) and bystander cardiopulmonary resuscitation (43.2% vs. 42.0%), more arrests in residential locations (77.3% vs. 73.0%) and were less likely to have shockable heart rhythm (23.5% vs. 27.9%). Temporal increases in return of spontaneous circulation and 30-day survival were seen for both groups (return of spontaneous circulation: 8.8% in 2001 to 22.3% in 2014 (diabetes patients) vs. 7.8% in 2001 to 25.7% in 2014 (non-diabetes patients); and 30-day survival: 2.8% in 2001 to 9.7% in 2014 vs. 3.5% to 14.8% in 2014, respectively). In adjusted models, diabetes was associated with decreased odds of return of spontaneous circulation (odds ratio 0.74 (95% confidence interval 0.66-0.82)) and 30-day survival (odds ratio 0.56 (95% confidence interval 0.48-0.65)) (interaction with calendar year p=0.434 and p=0.243, respectively).

CONCLUSION

No significant difference in temporal survival was found between the two groups. However, diabetes was associated with lower odds of return of spontaneous circulation and 30-day survival.

Good Samaritan Laws and Graduate Medical Education: A Tristate Survey

Objective

To assess the awareness of Good Samaritan laws among residents and fellows and the factors affecting the likelihood of a physician-in-training performing a Good Samaritan act.

Participants and Methods

A survey was distributed via official e-mail to Mayo Clinic residents and fellows at Mayo Clinic’s 3 locations: Rochester, Minnesota; Scottsdale, Arizona; and Jacksonville, Florida. The survey was open from August 4 to 25, 2015, at the Arizona and Florida sites and from August 10 to 31, 2015, at the Minnesota site. Responses were collected anonymously and analyzed, using descriptive statistics and regression models.

Results

The survey was sent to 1591 trainees and 19.7% (313) responded. Nearly half the respondents (49%) experienced a medical emergency that required assistance by a medically trained person and reported that increased medicolegal knowledge would increase their likelihood of helping (47%). Almost all (93.6%) felt that awareness of the Good Samaritan laws was essential for a medical professional and reported a need for further education to increase their knowledge (89.3%).

Conclusion

Residents and fellows asked for education about Good Samaritan laws and suggested that such education may increase their likelihood of helping in medical emergencies.

The effect of bystander cardiopulmonary resuscitation on the survival of out-of-hospital cardiac arrests: a systematic review and meta-analysis

Background

For many years, bystander cardiopulmonary resuscitation (BCPR) has been considered as a favorable factor to improve survival of out-of-hospital cardiac arrests (OHCAs). To examine the effect of BCPR on the survival of OHCAs and whether BCPR might also improve survival when the initial rhythm of OHCAs is limited, we performed a meta-analysis on published observational studies.

Methods

We did a systematic review to identify all studies published up to March, 2018, in any language, that reported the relation between BCPR and the survival of OHCAs. Using standard forms, two authors independently identified studies for inclusion and extracted information. The outcome was survival. Meta-regression was done to ascertain weighted factors for the outcomes.

Results

Data were extracted from 19 studies involving 232,703 patients. Firstly, pooled odds ratio (OR) from 16 cohort studies showed that BCPR was associated with improved chance of survival of OHCAs compared with NO-BCPR (OR 1.95, 95% confidence interval [CI]: 1.66–2.30). Secondly, from 8 cohort studies of OHCAs whose initial rhythm is limited, the pooled OR was 2.10 (95% CI, 1.68–2.63) of 6 articles for shockable rhythm and 1.07 (95% CI, 0.37–3.13) of 2 articles for non-shockable rhythm. Meta-regression showed a relation between the survival of OHCAs and BCPR was influenced by area (p < 0.05).

Conclusions

Based on currently available evidence, the findings of this meta-analysis suggest that BCPR increases the survival of OHCAs, and it also help OHCAs whose initial rhythm is shockable. That is to say BCPR is also helpful when emergency department response time is short. Therefore global priority should be given to increasing the incidence of BCPR by evidence-based best practice.

Korean Cardiac Arrest Research Consortium (KoCARC): rationale, development, and implementation

OBJECTIVE

This study aimed to describe the conceptualization, development, and implementation processes of the newly established Korean Cardiac Arrest Resuscitation Consortium (KoCARC) to improve out-of-hospital cardiac arrest (OHCA) outcomes.

METHODS

The KoCARC was established in 2014 by recruiting hospitals willing to participate voluntarily. To enhance professionalism in research, seven research committees, the Epidemiology and Preventive Research Committee, Community Resuscitation Research Committee, Emergency Medical System Resuscitation Research Committee, Hospital Resuscitation Research Committee, Hypothermia and Postresuscitation Care Research Committee, Cardiac Care Resuscitation Committee, and Pediatric Resuscitation Research Committee, were organized under a steering committee. The KoCARC registry was developed with variables incorporated in the currently existing regional OHCA registries and Utstein templates and were collected via a web-based electronic database system. The KoCARC study population comprises patients visiting the participating hospitals who had been treated by the emergency medical system for OHCA presumed to have a cardiac etiology.

RESULTS

A total of 62 hospitals volunteered to participate in the KoCARC, which captures 33.0% of the study population in Korea. Web-based data collection started in October 2015, and to date (December 2016), there were 3,187 cases compiled in the registry collected from 32 hospitals.

CONCLUSION

The KoCARC is a self-funded, voluntary, hospital-based collaborative research network providing high level evidence in the field of OHCA and resuscitation. This paper will serve as a reference for subsequent KoCARC manuscripts and for data elements collected in the study.

A Local Sensitivity Analysis of the Trial of Continuous or Interrupted Chest Compressions during Cardiopulmonary Resuscitation: Is a Local Protocol Change Required?

Objective

The “Trial of Continuous (CCC) or Interrupted Chest Compressions (ICC) during Cardiopulmonary Resuscitation (CPR)” compared two CPR strategies for out-of-hospital cardiac arrest (OHCA). Although results were neutral, there was suggestion of benefit for ICC. However, nearly 50% of study patients had a protocol violation; regional variations may have played a role in protocol adherence and outcomes. We analyzed our British Colombia (BC) cohort to decide whether a protocol change from CCC to ICC was justified.

Methods

This was a post-hoc analysis of BC-enrolled study patients. The primary between-group comparison was favorable neurological outcome (modified Rankin scale ≤ 3) using intention-to-treat. Secondary analyses compared those treated per-protocol (adjusted) and the top compliant clusters (unadjusted). We classified protocol violations using a structured algorithm. We used logistic regression and computed the difference in probabilities using the marginal standardization method with bootstrapping to calculate confidence intervals.

Results

There were 3769 patients included, with a median age of 69 years (IQR: 56–80). There were protocol violations in 3.2% of those in the CCC group and 27% of those in the ICC group. In patients randomized to CCC or ICC, 11.2% and 10.8% (risk difference 0.42%; 95% CI -1.58, 2.41) had favorable neurological outcomes, respectively. In the per-protocol and top compliant clusters comparisons, risk differences were 0.25% (95% CI -1.70, 2.25) and 2.95% (95% CI -0.68, 6.58).

Conclusion

Our comparisons suggest that CCC may be the preferred strategy in our region and is likely not resulting in worse outcomes. Based on the original study and our local analysis, we found no compelling reasons to change our local strategy from CCC to ICC.

Comparison of Cardiopulmonary Resuscitation Quality Between Standard Versus Telephone-Basic Life Support Training Program in Middle-Aged and Elderly Housewives: A Randomized Simulation Study

INTRODUCTION

For cardiac arrests witnessed at home, the witness is usually a middle-aged or older housewife. We compared the quality of cardiopulmonary resuscitation (CPR) performance of bystanders trained with the newly developed telephone-basic life support (T-BLS) program and those trained with standard BLS (S-BLS) training programs.

METHODS

Twenty-four middle-aged and older housewives without previous CPR education were enrolled and randomized into two groups of BLS training programs. The T-BLS training program included concepts and current instruction protocols for telephone-assisted CPR, whereas the S-BLS training program provided training for BLS. After each training course, the participants simulated CPR and were assisted by a dispatcher via telephone. Cardiopulmonary resuscitation quality was measured and recorded using a mannequin simulator. The primary outcome was total no-flow time (>1.5 seconds without chest compression) during simulation.

RESULTS

Among 24 participants, two (8.3%) who experienced mechanical failure of simulation mannequin and one (4.2%) who violated simulation protocols were excluded at initial simulation, and two (8.3%) refused follow-up after 6 months. The median (interquartile range) total no-flow time during initial simulation was 79.6 (66.4-96.9) seconds for the T-BLS training group and 147.6 (122.5-184.0) seconds for the S-BLS training group (P < 0.01). Median cumulative interruption time and median number of interruption events during BLS at initial simulation and 6-month follow-up simulation were significantly shorter in the T-BLS than in the S-BLS group (1.0 vs. 9.5, P < 0.01, and 1.0 vs. 10.5, P = 0.02, respectively).

CONCLUSIONS

Participants trained with the T-BLS training program showed shorter no-flow time and fewer interruptions during bystander CPR simulation assisted by a dispatcher.

Is initial rhythm in OHCA a predictor of preceding no flow time? Implications for bystander response and ECPR candidacy evaluation

OBJECTIVE

Shockable cardiac rhythms are associated with improved outcomes among out-of-hospital cardiac arrests (OHCA). Initial cardiac rhythm may also be predictive of a short preceding no-flow duration. We examined the relationship between no-flow duration and initial cardiac rhythm, which may demonstrate the urgency in rescuer response and assist with candidacy evaluation for extracorporeal-cardiopulmonary resuscitation (ECPR).

METHODS

We examined consecutive adult OHCA's identified by a prospective registry in British Columbia (2005-2016). We included those with witnessed OHCA but no bystander CPR. The variable of interest was no-flow duration, defined as time from 9-1-1 call to EMS arrival. We fit an adjusted logistic regression model to estimate the association of no-flow duration and initial cardiac rhythm. Among those with shockable initial rhythms, we calculated the cumulative proportion with no-flow durations under incremental time cut-offs.

RESULTS

Of 26 621 EMS-treated OHCA's, 2532 were included. Overall survival was 13.8%, and 34% had initial shockable rhythms. The probability of having an initial shockable rhythm decreased with increasing no-flow durations (adjusted OR 0.88 per minute, 95% CI 0.85-0.91). Among those found with initial shockable rhythms, 94% (95% CI 92-96%) had a no-flow time under 10 min.

CONCLUSION

The odds of a shockable initial rhythm declined with each additional minute of no-flow time, highlighting the importance of early access to defibrillation. Among those with initial shockable rhythms, the preceding no-flow duration was highly likely to be under 10 min, which may inform decisions about ECPR candidacy among select patients with unwitnessed arrests.

The Pan-Asian Resuscitation Outcomes Study (PAROS) clinical research network: what, where, why and how

Out-of-hospital cardiac arrest (OHCA) is a global health concern with an incidence rate of 50-60 per 100,000 person-years. To improve OHCA survival rates, several cardiac arrest registries have been set up in North America and Europe, such as the Resuscitation Outcomes Consortium, Cardiac Arrest Registry to Enhance Survival, Ontario Prehospital Advanced Life Support and European Registry of Cardiac Arrest. In Asia, however, there was previously no concerted effort in prehospital emergency care research owing to differences in prehospital emergency medical services systems, data collection methods and outcome reporting between countries. Recognising the need for a collaborative prehospital emergency care research group in Asia, researchers from seven countries in the Asia-Pacific region (including Japan, South Korea, Taiwan, Thailand, United Arab Emirates-Dubai, Singapore and Malaysia) established the Pan-Asian Resuscitation Outcomes Study (PAROS) clinical research network in 2010. This paper gives the overview, methodology and research accomplishments of the PAROS network.

Out-of-hospital cardiac arrest: prehospital management

Sudden out-of-hospital cardiac arrest is the most time-critical medical emergency. In the second paper of this Series on out-of-hospital cardiac arrest, we considered important issues in the prehospital management of cardiac arrest. Successful resuscitation relies on a strong chain of survival with the community, dispatch centre, ambulance, and hospital working together. Early cardiopulmonary resuscitation and defibrillation has the greatest impact on survival. If the community response does not restart the heart, resuscitation is continued by emergency medical services' staff. However, the best approaches for airway management and the effectiveness of currently used drug treatments are uncertain. Prognostic factors and rules for termination of resuscitation could guide the duration of a resuscitation attempt and decision to transport to hospital. If return of spontaneous circulation is achieved, the focus of treatment shifts to stabilisation, restoration of normal physiological parameters, and transportation to hospital for ongoing care.

The Association of Prehospital Intravenous Fluids and Mortality in Patients with Penetrating Trauma

BACKGROUND

The optimal approach to prehospital care of trauma patients is controversial, and thought to require balancing advanced field interventions with rapid transport to definitive care.

OBJECTIVE

We sought principally to examine any association between the amount of prehospital IV fluid (IVF) administered and mortality.

METHODS

We conducted a retrospective cohort analysis of trauma registry data patients who sustained penetrating trauma between January 2008 and February 2011, as identified in the Pennsylvania Trauma Systems Foundation registry with corresponding prehospital records from the Philadelphia Fire Department. Analyses were conducted with logistic regression models and instrumental variable analysis, adjusted for injury severity using scene vital signs before the intervention was delivered.

RESULTS

There were 1966 patients identified. Overall mortality was 22.60%. Approximately two-thirds received fluids and one-third did not. Both cohorts had similar Trauma and Injury Severity Score-predicted mortality. Mortality was similar in those who received IVF (23.43%) and those who did not (21.30%) (p = 0.212). Patients who received IVF had longer mean scene times (10.82 min) than those who did not (9.18 min) (p < 0.0001), although call times were similar in those who received IVF (24.14 min) and those who did not (23.83 min) (p = 0.637). Adjusted analysis of 1722 patients demonstrated no benefit or harm associated with prehospital fluid (odds ratio [OR] 0.905, 95% confidence interval [CI] 0.47-1.75). Instrumental variable analysis utilizing variations in use of IVF across different Emergency Medical Services (EMS) units also found no association between the unit's percentage of patients that were provided fluids and mortality (OR 1.02, 95% CI 0.96-1.08).

CONCLUSIONS

We found no significant difference in mortality or EMS call time between patients who did or did not receive prehospital IVF after penetrating trauma.

The Efficacy of Alternative Cardiopulmomonary Resuscitation Methods When Compared to Standard Cardiopulmonary Resuscitation: A Simulation Study

Objective

There are limited data comparing the alternative cardiopulmomary resuscitation (CPR) methods (over the head CPR, straddle CPR and one hand CPR) to standard CPR performed by emergency medical technicians (EMTs). Therefore we investigated the efficacy of the alternative CPRs compared to that of standard CPR performed by EMTs in simulated cardiac arrest scenarios.

Methods

Thirty EMTs of intermediate level participated in this study. The performance of CPR was defined as the average depth, the total number of chest compressions, and the rate of compressions. EMTs performed three minutes of standard CPR and of alternative CPR on standard simulation mannequins with recording devices. Recorded performance was measured and compared between subgroups by the type of CPR, gender of EMTs and gender with various methods of CPR using ANOVA and t test statistics.

Results

The average depth of compressions was 42.3±5.8, 42.6±4.7, 43.5±3.7, 33.8±6.6 mm (mean±standard deviation) respectively in standard CPR, over the head CPR, straddle CPR and one hand CPR. The total number of chest compression was 330.4±38.1, 334.8±70.2, 334.0±34.9, 312.1±53.5 in 3 minutes. The rate of compressions was found to be 111.5±10.3, 113.8±11.6, 110.5±11.2, 110.7±11.8 times per minute. The comparison of the performance qualities for the four types of CPR showed that the compression depth was significantly lower in one-hand CPR (p<0.000). No EMT gender difference in the quality of performance of total CPR was noted.

Conclusions

The efficacy of alternative CPRs are shown to be similar to that of standard CPR in a compression-only simulation cardiac arrest model.

Modifiable Factors Associated With Survival After Out-of-Hospital Cardiac Arrest in the Pan-Asian Resuscitation Outcomes Study

STUDY OBJECTIVE

The study aims to identify modifiable factors associated with improved out-of-hospital cardiac arrest survival among communities in the Pan-Asian Resuscitation Outcomes Study (PAROS) Clinical Research Network: Japan, Singapore, South Korea, Malaysia, Taiwan, Thailand, and the United Arab Emirates (Dubai).

METHODS

This was a prospective, international, multicenter cohort study of out-of-hospital cardiac arrest in the Asia-Pacific. Arrests caused by trauma, patients who were not transported by emergency medical services (EMS), and pediatric out-of-hospital cardiac arrest cases (<18 years) were excluded from the analysis. Modifiable out-of-hospital factors (bystander cardiopulmonary resuscitation [CPR] and defibrillation, out-of-hospital defibrillation, advanced airway, and drug administration) were compared for all out-of-hospital cardiac arrest patients presenting to EMS and participating hospitals. The primary outcome measure was survival to hospital discharge or 30 days of hospitalization (if not discharged). We used multilevel mixed-effects logistic regression models to identify factors independently associated with out-of-hospital cardiac arrest survival, accounting for clustering within each community.

RESULTS

Of 66,780 out-of-hospital cardiac arrest cases reported between January 2009 and December 2012, we included 56,765 in the analysis. In the adjusted model, modifiable factors associated with improved out-of-hospital cardiac arrest outcomes included bystander CPR (odds ratio [OR] 1.43; 95% confidence interval [CI] 1.31 to 1.55), response time less than or equal to 8 minutes (OR 1.52; 95% CI 1.35 to 1.71), and out-of-hospital defibrillation (OR 2.31; 95% CI 1.96 to 2.72). Out-of-hospital advanced airway (OR 0.73; 95% CI 0.67 to 0.80) was negatively associated with out-of-hospital cardiac arrest survival.

CONCLUSION

In the PAROS cohort, bystander CPR, out-of-hospital defibrillation, and response time less than or equal to 8 minutes were positively associated with increased out-of-hospital cardiac arrest survival, whereas out-of-hospital advanced airway was associated with decreased out-of-hospital cardiac arrest survival. Developing EMS systems should focus on basic life support interventions in out-of-hospital cardiac arrest resuscitation.

Incidence and survival outcome according to heart rhythm during resuscitation attempt in out-of-hospital cardiac arrest patients with presumed cardiac etiology

BACKGROUND

Knowledge about heart rhythm conversion from non-shockable to shockable rhythm during resuscitation attempt after out-of-hospital cardiac arrest (OHCA) and following chance of survival is limited and inconsistent.

METHODS

We studied 13,860 patients with presumed cardiac-caused OHCA not witnessed by the emergency medical services from the Danish Cardiac Arrest Register (2005-2012). Patients were stratified according to rhythm: shockable, converted shockable (based on receipt of subsequent defibrillation) and sustained non-shockable rhythm. Multiple logistic regression was used to identify predictors of rhythm conversion and to compute 30-day survival chances.

RESULTS

Twenty-five percent of patients who received pre-hospital defibrillation by ambulance personnel were initially found in non-shockable rhythms. Younger age, males, witnessed arrest, shorter response time, and heart disease were significantly associated with conversion to shockable rhythm, while psychiatric- and chronic obstructive pulmonary disease were significantly associated with sustained non-shockable rhythm. Compared to sustained non-shockable rhythms, converted shockable rhythms and initial shockable rhythms were significantly associated with increased 30-day survival (Adjusted odds ratio (OR) 2.6, 95% confidence interval (CI): 1.8-3.8; and OR 16.4, 95% CI 12.7-21.2, respectively). From 2005 to 2012, 30-day survival chances increased significantly for all three groups: shockable rhythms, from 16.3% (CI: 14.2%-18.7%) to 35.7% (CI: 32.5%-38.9%); converted rhythms, from 2.1% (CI: 1.6%-2.9%) to 5.8% (CI: 4.4%-7.6%); and sustained non-shockable rhythms, from 0.6% (CI: 0.5%-0.8%) to 1.8% (CI: 1.4%-2.2%).

CONCLUSION

Converting to shockable rhythm during resuscitation attempt was common and associated with nearly a three-fold higher odds of 30-day survival compared to sustained non-shockable rhythms.

Basic life support education in secondary schools: a cross-sectional survey in London, UK

OBJECTIVES

Basic life support (BLS) training in schools is associated with improved outcomes from cardiac arrest. International consensus statements have recommended universal BLS training for school-aged children. The current practice of BLS training in London schools is unknown. The aim of this study was to assess current practices of BLS training in London secondary schools.

SETTING, POPULATION AND OUTCOMES

A prospective audit of BLS training in London secondary schools was conducted. Schools were contacted by email, and a subsequent telephone interview was conducted with staff familiar with local training practices. Response data were anonymised and captured electronically. Universal training was defined as any programme which delivers BLS training to all students in the school. Descriptive statistics were used to summarise the results.

RESULTS

A total of 65 schools completed the survey covering an estimated student population of 65 396 across 19 of 32 London boroughs. There were 5 (8%) schools that provide universal training programmes for students and an additional 31 (48%) offering training as part of an extracurricular programme or chosen module. An automated external defibrillator (AED) was available in 18 (28%) schools, unavailable in 40 (61%) and 7 (11%) reported their AED provision as unknown. The most common reasons for not having a universal BLS training programme are the requirement for additional class time (28%) and that funding is unavailable for such a programme (28%). There were 5 students who died from sudden cardiac arrest over the period of the past 10 years.

CONCLUSIONS

BLS training rates in London secondary schools are low, and the majority of schools do not have an AED available in case of emergency. These data highlight an opportunity to improve BLS training and AEDs provision. Future studies should assess programmes which are cost-effective and do not require significant amounts of additional class time.

Bystander fatigue and CPR quality by older bystanders: a randomized crossover trial comparing continuous chest compressions and 30:2 compressions to ventilations

Objectives

This study sought to measure bystander fatigue and cardiopulmonary resuscitation (CPR) quality after five minutes of CPR using the continuous chest compression (CCC) versus the 30:2 chest compression to ventilation method in older lay persons, a population most likely to perform CPR on cardiac arrest victims.

Methods

This randomized crossover trial took place at three tertiary care hospitals and a seniors’ center. Participants were aged ≥55 years without significant physical limitations (frailty score ≤3/7). They completed two 5-minute CPR sessions (using 30:2 and CCC) on manikins; sessions were separated by a rest period. We used concealed block randomization to determine CPR method order. Metronome feedback maintained a compression rate of 100/minute. We measured heart rate (HR), mean arterial pressure (MAP), and Borg Exertion Scale. CPR quality measures included total number of compressions and number of adequate compressions (depth ≥5 cm).

Results

Sixty-three participants were enrolled: mean age 70.8 years, female 66.7%, past CPR training 60.3%. Bystander fatigue was similar between CPR methods: mean difference in HR -0.59 (95% CI −3.51-2.33), MAP 1.64 (95% CI −0.23-3.50), and Borg 0.46 (95% CI 0.07-0.84). Compared to 30:2, participants using CCC performed more chest compressions (480.0 v. 376.3, mean difference 107.7; p<0.0001) and more adequate chest compressions (381.5 v. 324.9, mean difference. 62.0; p=0.0001), although good compressions/minute declined significantly faster with the CCC method (p=0.0002).

Conclusions

CPR quality decreased significantly faster when performing CCC compared to 30:2. However, performing CCC produced more adequate compressions overall with a similar level of fatigue compared to the 30:2 method.