Organisation of prehospital care: the French experience

The peak end-tidal carbon dioxide concentration recorded during cardiopulmonary resuscitation as an indicator of survival: a nationwide cohort study of pediatric out-of-hospital cardiac arrests

BACKGROUND

Although the end-tidal carbon dioxide concentration (ETCO2) recorded during resuscitation has been reported as an indicator of survival in a few studies of pediatric in-hospital cardiac arrest, the relationship between ETCO2 and survival in pediatric out-of-hospital cardiac arrest (OHCA) has not previously been investigated (particularly with regard to the cause of the OHCA). This study aimed to determine whether quantitative measurement of ETCO2 during resuscitation is predictive of survival in cases of pediatric OHCA.

METHOD

This nationwide, population-based cohort study analyzed data from the French RéAC OHCA registry, including all patients under 18 years of age with trauma-related OHCA or medical OHCA from 2011 to 2023. The highest ETCO2 value was recorded during advanced cardiopulmonary resuscitation. The main outcomes were return of spontaneous circulation (ROSC) and day (d)30 survival. Discriminant ability was evaluated using the area under the receiver operating characteristic curve (AUROC), and the Youden index was used to determine the optimal ETCO2 cut-off value.

RESULTS

A total of 1209 pediatric OHCAs (226 (19%) trauma-related and 983 (81%) medical) were included. The victims' median [interquartile range] age was 6 [0;14] years. ROSC was achieved in 347 (29%) cases and d30 survival was achieved in 61 (5%) cases. In both trauma-related and medical OHCAs, the peak recorded ETCO2 value was higher in patients who achieved ROSC and in d30 survivors. The AUROC [95% confidence interval] for the highest ETCO2 that predicted ROSC and d30 survival were respectively 0.808 [0.745-0.872] and 0.854 [0.761-0.947] for the trauma-related OHCA group and 0.803 [0.774-0.831] and 0.732 [0.676-0.787] for the medical OHCA group. In both groups, the probability of ROSC and d30 survival increased with higher ETCO2 values, with optimal cut-offs of 21 and 29 mmHg for trauma-related OHCA and 27 and 26 mmHg for medical OHCA, respectively.

CONCLUSIONS

Further studies are necessary to clarify the use of ETCO2 in optimizing pediatric ALS.

Factors affecting communication time in an emergency medical communication centers

BACKGROUND

Emergency Medical Communication Centres (EMCCs) play a crucial role in emergency care by ensuring timely responses through telephone triage. However, extended communication times can impede accessibility, patient triage, and decision-making. Identifying the factors influencing communication duration is essential for improving EMCC efficiency.

OBJECTIVE

This study aims to identify temporal, human, and contextual factors associated with prolonged communication times in an EMCC where decision-making is conducted by physicians.

METHODS

We conducted a retrospective observational study of all calls received at a French EMCC between March 1 and December 31, 2019. A total of 108,548 patient medical files were analyzed, excluding calls from medical personnel or hospitals. We examined the total communication time (from call initiation to decision) and the medical communication time (physician involvement). Bivariate and multivariate logistic regressions were used to identify factors associated with prolonged communication times.

RESULTS

The median total communication time was 7 min [IQR 5-11], and the median medical communication time was 3 min [IQR 2-4]. Psychiatric reasons for calling (OR = 1.75) and elderly patients (OR = 1.58) were associated with longer communication times. Calls leading to medical advice (OR = 1.48) and calls during weekends or nighttime were also significant factors. Conversely, calls for trauma or from nursing homes, and those handled by emergency physicians, were associated with shorter durations.

CONCLUSION

Several factors influence communication times in EMCCs, including patient demographics, reason for the call, and time of day.

The association between the type of bystander and survival after an out-of-hospital cardiac arrest: A French nationwide study

Background

Early bystander interventions are associated with more favorable outcomes after out-of-hospital cardiac arrest (OHCA). The objective of the present study was to determine whether the type of bystander-patient relationship was associated with survival and neurological outcomes after OHCA in France.

Methods

We analyzed data registered in the French National Cardiac Arrest Registry (RéAC) between July 1st, 2011, and April 30th, 2023. The study population comprised bystander-attended cases of OHCA managed by the emergency medical services. Bystanders were categorized as family members, other laypersons, off-duty professional first responders, or off-duty healthcare professionals. The primary outcome was 30-day survival with a favorable neurological outcome (Cerebral Performance Category 1 or 2). The secondary outcomes included the bystander cardiopulmonary resuscitation (CPR) initiation rate, return of spontaneous circulation, and survival upon admission to the hospital. Our statistical analyses were based on bivariate and multivariable logistic regressions analyses.

Results

Among the 89,861 OHCA cases analyzed, family members constituted the largest group of bystanders (69.2%). Compared with non-family-member bystanders, family bystander status was associated with a lower CPR initiation rate, a longer no-flow time, and lower 30-day survival rates. Specifically, cases of OHCA with non-family-member bystanders were 32% more likely to survive with a CPC of 1-2 at day 30 than cases with family member bystanders. Medically trained bystander status (off-duty professional first responders and healthcare professionals) was associated with higher CPR initiation and 30-day survival rates, relative to nontrained laypersons.

Conclusions

Survival after an OHCA appears to be associated with the type of bystander. Although family members were the most common bystanders, they were less likely to initiate CPR and less likely to see the OHCA patient survive. Efforts to increase the post-OHCA survival rate should include targeted interventions (such as public education and training programs) that emphasize the importance of early CPR and automated external defibrillator use by family members.

Outcome from out-of-hospital cardiac arrest managed by the pre-hospital emergency medical system in Martinique, a French Caribbean Overseas Territory

Introduction

Out-of-hospital cardiac arrest (OHCA) affects approximately 46,000 people in France annually and survival remains low. There is no published data specific to the characteristics and outcomes of OHCA in French overseas territories, especially in the French Caribbean territories. The aim of this study was to describe the characteristics and outcomes of adult OHCA patients managed by the Emergency Medical Service team (EMS) in Martinique.

Methods

All adults with OHCA, managed by the EMS of Martinique between January 1st 2018 and June 30th 2019, were included. Primary outcome was 30 day-survival and neurological outcome at 30 days assessed by the Cerebral Performance Category scale (CPC). Secondary outcomes were return of spontaneous circulation (ROSC) prior to hospital admission and causes of cardiac arrest in patients with ROSC.

Results

This study included 340 OHCA patients. The population was predominantly male (64%), with a median age of 68 [54-78] years. OHCA resulted from a medical condition in 314 patients (92%) and occurred mainly at home (75%), in the presence of witnesses for 235 patients (69%). Basic life support was initiated in 174 OHCA (51%). Median time to first-responders' and prehospital mobile intensive care unit's arrivals at scene were 17 [10-30] and 27 [19-41] minutes after call to the EMS dispatching center for OHCA. Non-shockable initial rhythm was present in 315 patients (93%), and 240 patients (71%) received advanced life support. Thirty-one patients (9%) achieved ROSC. On day 30, 13 patients (3.8%) were still alive, and 8 of them (2.4%) were alive with a CPC score of 1 or 2.

Conclusion

The overall adult OHCA survival rate and survival with good neurological status on day-30 in the French Caribbean island of Martinique are low. OHCA survival rate may be improved by educating the population on basic life support techniques and reducing the time responses for first-responders and prehospital mobile intensive care unit to reach patients.

Early point-of-care echocardiography as a predictive factor for absence of return of spontaneous circulatory in out-of-hospital cardiac arrests: A multicentre observational study

INTRODUCTION

Early assessment of the prognosis of a patient in cardiac arrest during cardiopulmonary resuscitation is highly challenging. This study aims to evaluate the predictive outcome value of early point-of-care ultrasound (POCUS) in out-of-hospital settings.

METHODS

This observational, prospective, multicentre study's primary endpoint was the positive predictive value (PPV) of POCUS cardiac standstill within the first 12 min of advanced life support (ALS) initiation in determining the absence of return of spontaneous circulation (ROSC). A multivariate logistic regression model was constructed with adjustments for known predictive variables typically used in termination of resuscitation (TOR) rules.

RESULTS

A total of 293 patients were analysed, with a mean age of 66.6 ± 14.6 years, and a majority were men (75.8%). POCUS was performed on average 7.9 ± 2.6 min after ALS initiation. Among patients with cardiac standstill (72.4%), 16.0% achieved ROSC compared with 48.2% in those with visible cardiac motions. The PPV of early POCUS cardiac standstill for the absence of ROSC was 84.0%, 95% CI [78.3-88.6]. In multivariable analysis, only POCUS cardiac standstill (adjusted odds ratio [aOR] 3.89, 95% CI [1.86-8.17]) and end-tidal CO2 (ETCO2) value ≤37 mmHg (aOR 4.27, 95% CI [2.21-8.25]) were associated with the absence of ROSC.

CONCLUSION

Early POCUS cardiac standstill during CPR for out-of-hospital cardiac arrest was a reliable predictor of the absence of ROSC. However, its presence alone was not sufficient to determine the termination of resuscitation efforts.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03494153. Registered March 29, 2018.

HIV status and lay bystander cardiopulmonary resuscitation initiation for witnessed cardiac arrest

INTRODUCTION

Early initiation of cardiopulmonary resuscitation (CPR) by bystanders of out-of-hospital cardiac arrest (OHCA) significantly improves survival and neurological outcomes. However, misconceptions about human immunodeficiency virus (HIV) transmission risk during CPR can deter lay bystanders from performing resuscitation. The aim of this study was to compare the rate of CPR initiation by lay bystanders who witnessed OHCA in subjects with and without HIV infection.

METHODS

We analysed data from the two French cardiac arrest registries (SDEC and RéAC) from 2012 to 2020. We identified HIV-positive individuals from the French National Health Insurance database for the SDEC registry, and directly from the RéAC registry data. We used logistic regression models to assess the association between CPR initiation by lay bystanders and the victim's HIV status.

RESULTS

Of 58,177 witnessed OHCA cases, 192 (0.3%) occurred in HIV-positive subjects. These individuals were younger, more often male, and presented more shockable initial rhythms compared with subjects without HIV. Overall, there was no difference in the CPR initiation rate according to the HIV status (57.3% vs 47.6%, adjusted odds ratio 1.11, 95% confidence interval 0.83-1.48). The CPR initiation rate also did not differ by location between victims with or without HIV (home: 57.7% vs 45.4%; public places: 56.0% vs 53.6%; p for interaction = 0.46). Survival and neurological outcomes at hospital discharge did not differ based on the HIV status.

CONCLUSIONS

This study revealed that the rate of CPR initiation by lay bystanders did not differ between HIV and non-HIV subjects during OHCA.

Impact of delayed mobile medical team dispatch for respiratory distress calls: a propensity score matched study from a French emergency communication center

BACKGROUND

Shortness of breath is a common complaint among individuals contacting emergency communication center (EMCCs). In some prehospital system, emergency medical services include an advanced life support (ALS)-capable team. Whether such team should be dispatched during the phone call or delayed until the BLS-capable paramedic team reports from the scene is unclear. We aimed to evaluate the impact of delayed MMT dispatch until receiving the paramedic review compared to immediate dispatch at the time of the call on patient outcomes.

METHODS

A cross-sectional study conducted in Lyon, France, using data obtained from the departmental EMCC during the period from January to December 2019. We included consecutive calls related to adult patients experiencing acute respiratory distress. Patients from the two groups (immediate mobile medical team (MMT) dispatch or delayed MMT dispatch) were matched on a propensity score, and a conditional weighted logistic regression assessed the adjusted odds ratios (ORs) for each outcome (mortality on days 0, 7 and 30).

RESULTS

A total of 870 calls (median age 72 [57-84], male 466 53.6%) were sought for analysis [614 (70.6%) "immediate MMT dispatch" and 256 (29.4%) "delayed MMT" groups]. The median time before MMT dispatch was 25.1 min longer in the delayed MMT group (30.7 [26.4-36.1] vs. 5.6 [3.9-8.8] min, p < 0.001). Patients subjected to a delayed MMT intervention were older (median age 78 [66-87] vs. 69 [53-83], p < 0.001) and more frequently highly dependent (16.3% vs. 8.6%, p < 0.001). A higher proportion of patients in the delayed MMT group required bag valve mask ventilation (47.3% vs. 39.1%, p = 0.03), noninvasive ventilation (24.6% vs. 20.0%, p = 0.13), endotracheal intubation (7.0% vs. 4.1%, p = 0.07) and catecholamine infusion (3.9% vs. 1.3%, p = 0.01). After propensity score matching, mortality at day 0 was higher in the delayed MMT group (9.8% vs. 4.2%, p = 0.002). Immediate MMT dispatch at the call was associated with a lower risk of mortality on day 0 (0.60 [0.38;0.82], p < 0.001) day 7 (0.50 [0.27;0.72], p < 0.001) and day 30 (0.56 [0.35;0.78], p < 0.001) CONCLUSIONS: This study suggests that the deployment of an MMT at call in patients in acute respiratory distress may result in decreased short to medium-term mortality compared to a delayed MMT following initial first aid assessment.

Telemedicine in Nursing Home Residents Requiring a Call to an Emergency Medical Communication Center

OBJECTIVES

To compare the proportion of nursing home residents dispatched to an emergency department (ED) after a call to the emergency medical communication center (EMCC) according to the availability or nonavailability of telemedicine.

DESIGN

This prospective, observational trial was conducted in the EMCC and 74 nursing homes in a French county.

SETTING AND PARTICIPANTS

All nursing home residents who needed to contact the EMCC between June 2019 and April 2020 were included in the study. We excluded calls notifying the death of a resident, for completing data from a previous call, and for nursing home staff.

METHODS

The primary outcome was the proportion of residents dispatched to an ED after their first call to the EMCC. The secondary outcomes were the proportion of second calls, proportion of residents dispatched to an ED after a second call, and proportion of death within 30 days.

RESULTS

We included 3103 calls in the final analysis (355 from equipped nursing homes and 2748 from unequipped nursing homes). The proportion of patients dispatched to an ED after the first call was lower among telemedicine-equipped than among telemedicine-unequipped nursing homes (41% vs 50%; odds ratio, 0.71; 95% CI, 0.56-0.90). The proportion of a second call for the same purpose within 72 hours, proportion of dispatching to an ED at the second call, and proportion of deaths within 30 days were similar between the groups.

CONCLUSION AND IMPLICATIONS

The use of telemedicine by nursing home residents requiring a call to the EMCC is associated with a reduction in the number of dispatches to an ED without any increase in the number of 72-hour callbacks or 30-day mortality rates.

Ketamine Compared With Morphine for Out-of-Hospital Analgesia for Patients With Traumatic Pain: A Randomized Clinical Trial

Importance

Pain is a common out-of-hospital symptom among patients, and opioids are often prescribed. Research suggests that overprescribing for acute traumatic pain is still prevalent, even when limits restricting opioid prescriptions have been implemented. Ketamine hydrochloride is an alternative to opioids in adults with out-of-hospital traumatic pain.

Objective

To assess the noninferiority of intravenous ketamine compared with intravenous morphine sulfate to provide pain relief in adults with out-of-hospital traumatic pain.

Design, Setting, and Participants

The Intravenous Subdissociative-Dose Ketamine Versus Morphine for Prehospital Analgesia (KETAMORPH) study was a multicenter, single-blind, noninferiority randomized clinical trial comparing ketamine hydrochloride (20 mg, followed by 10 mg every 5 minutes) with morphine sulfate (2 or 3 mg every 5 minutes) in adult patients with out-of-hospital trauma and a verbal pain score equal to or greater than 5. Enrollment occurred from November 23, 2017, to November 26, 2022, in 11 French out-of-hospital emergency medical units.

Interventions

Patients were randomly assigned to ketamine (n = 128) or morphine (n = 123).

Main Outcomes and Measures

The primary outcome was the between-group difference in mean change in verbal rating scale pain scores measured from the time before administration of the study drug to 30 minutes later. A noninferiority margin of 1.3 was chosen.

Results

A total of 251 patients were randomized (median age, 51 [IQR, 34-69] years; 111 women [44.9%] and 140 men [55.1%] among the 247 with data available) and were included in the intention-to-treat population. The mean pain score change was -3.7 (95% CI, -4.2 to -3.2) in the ketamine group compared with -3.8 (95% CI, -4.2 to -3.4) in the morphine group. The difference in mean pain score change was 0.1 (95% CI, -0.7 to 0.9) points. There were no clinically meaningful differences for vital signs between the 2 groups. The intravenous morphine group had 19 of 113 (16.8% [95% CI, 10.4%-25.0%]) adverse effects reported (most commonly nausea [12 of 113 (10.6%)]) compared with 49 of 120 (40.8% [95% CI, 32.0%-49.6%]) in the ketamine group (most commonly emergence phenomenon [24 of 120 (20.0%)]). No adverse events required intervention.

Conclusions and Relevance

In the KETAMORPH study of patients with out-of-hospital traumatic pain, the use of intravenous ketamine compared with morphine showed noninferiority for pain reduction. In the ongoing opioid crisis, ketamine administered alone is an alternative to opioids in adults with out-of-hospital traumatic pain.

Trial Registration

ClinicalTrials.gov Identifier: NCT03236805.

Cumulative dose of epinephrine and mode of death after non-shockable out-of-hospital cardiac arrest: a registry-based study

BACKGROUND

Epinephrine increases the chances of return of spontaneous circulation (ROSC) in out-of-hospital cardiac arrest (OHCA), especially when the initial rhythm is non-shockable. However, this drug could also worsen the post-resuscitation syndrome (PRS). We assessed the association between epinephrine use during cardiopulmonary resuscitation (CPR) and subsequent intensive care unit (ICU) mortality in patients with ROSC after non-shockable OHCA.

METHODS

We used data prospectively collected in the Sudden Death Expertise Center (SDEC) registry (capturing OHCA data located in the Greater Paris area, France) between May 2011 and December 2021. All adults with ROSC after medical, cardiac and non-cardiac causes, non-shockable OHCA admitted to an ICU were included. The mode of death in the ICU was categorized as cardiocirculatory, neurological, or other.

RESULTS

Of the 2,792 patients analyzed, there were 242 (8.7%) survivors at hospital discharge, 1,004 (35.9%) deaths from cardiocirculatory causes, 1,233 (44.2%) deaths from neurological causes, and 313 (11.2%) deaths from other etiologies. The cardiocirculatory death group received more epinephrine (4.6 ± 3.8 mg versus 1.7 ± 2.8 mg, 3.2 ± 2.6 mg, and 3.5 ± 3.6 mg for survivors, neurological deaths, and other deaths, respectively; p < 0.001). The proportion of cardiocirculatory death increased linearly (R2 = 0.92, p < 0.001) with cumulative epinephrine doses during CPR (17.7% in subjects who did not receive epinephrine and 62.5% in those who received > 10 mg). In multivariable analysis, a cumulative dose of epinephrine was strongly associated with cardiocirculatory death (adjusted odds ratio of 3.45, 95% CI [2.01-5.92] for 1 mg of epinephrine; 12.28, 95% CI [7.52-20.06] for 2-5 mg; and 23.71, 95% CI [11.02-50.97] for > 5 mg; reference 0 mg; population reference: alive at hospital discharge), even after adjustment on duration of resuscitation. The other modes of death (neurological and other causes) were also associated with epinephrine use, but to a lesser extent.

CONCLUSIONS

In non-shockable OHCA with ROSC, the dose of epinephrine used during CPR is strongly associated with early cardiocirculatory death. Further clinical studies aimed at limiting the dose of epinephrine during CPR seem warranted. Moreover, strategies for the prevention and management of PRS should take this dose of epinephrine into consideration for future trials.

Predictive factors for early requirement of respiratory support through phone call to Emergency Medical Call Centre for dyspnoea: a retrospective cohort study

BACKGROUND

Acute dyspnoea is a common symptom in Emergency Medicine, and severity assessment is difficult during the first time the patient calls the Emergency Medical Call Centre.

OBJECTIVE

To identify predictive factors regarding the need for early respiratory support in patients who call the Emergency Medical Call Centre for dyspnoea.

DESIGN, SETTINGS AND PARTICIPANTS

This retrospective cohort study carried out in the Emergency Medical Call Centre of the University Hospital of Toulouse from 1 July to 31 December 2019. Patients over the age of 15 who call the Emergency Medical Call Centre regarding dyspnoea and who were registered at the University Hospital or died before admission were included in our study.

OUTCOME MEASURE AND ANALYSIS

The primary end-point was early requirement of respiratory support [including high-flow oxygen, non-invasive ventilation (NIV) or mechanical ventilation after intubation] that was initiated by the physicians staffed ambulance before admission to the hospital or within 3 h after being admitted. Associations with patients' characteristics identified during Emergency Medical Call Centre calls were assessed with a backward stepwise logistic regression after multiple imputations for missing values.

MAIN RESULTS

During the 6-month inclusion period, 1425 patients called the Emergency Medical Call Centre for respiratory issues. After excluding 38 calls, 1387 were analyzed, including 208 (15%) patients requiring respiratory support. The most frequent respiratory support used was NIV (75%). Six independent predictive factors of requirement of respiratory support were identified: chronic β2-mimetics medication [odds ratio (OR) = 2.35, 95% confidence interval (CI) 1.61-3.44], polypnea (OR = 5.78, 95% CI 2.74-12.22), altered ability to speak (OR = 2.35, 95% CI 1.55-3.55), cyanosis (OR = 2.79, 95% CI 1.81-4.32), sweats (OR = 1.93, 95% CI 1.25-3) and altered consciousness (OR = 1.8, 95% CI 1.1-3.08).

CONCLUSION

During first calls for dyspnoea, six predictive factors are independently associated with the risk of early requirement of respiratory support.

Out-of-hospital cardiac arrests occurring at school in France: A nation-wide retrospective cohort study from the RéAC registry

AIM

We sought to describe the characteristics of at-school out-of-hospital cardiac arrests cases, subsequent basic life support, as well as ultimate patient outcomes.

METHODS

This was a nation-wide, multicentre, retrospective cohort study from the French national population-based RéAC out-of-hospital cardiac arrest registry (July 2011 - March 2023). We compared the characteristics and outcomes of cases occurring at schools vs. in other public places.

RESULTS

Of the 149,088 national out-of-hospital cardiac arrests, 25,071 were public: 86 (0.3%) and 24,985 (99.7%) in schools and other public places, respectively. At-school out-of-hospital cardiac arrests, in comparison to other public places, were: significantly younger (median: 42.5 vs. 58 years, p < 0.001); more commonly of a medical cause (90.7% vs. 63.8%, p < 0.001), more commonly bystander-witnessed (93.0% vs. 73.4%, p < 0.001) and recipients of bystander cardiopulmonary resuscitation (78.8% vs. 60.6%, p = 0.001) with shorter median no-flow durations (2 min. vs. 7 min.); with greater bystander automated external defibrillator application (38.9% vs. 18.4%) and defibrillation (23.6%, vs. 7.9%; all p < 0.001). At-school patients had greater rates of return of spontaneous circulation than out-of-school ones (47.7%, vs. 31.8%; p = 0.002), higher rates of survival at arrival at hospital (60.5% vs. 30.7%; p < 0.001) and at 30-days (34.9% vs. 11.6%; p < 0.001), and survival with favourable neurological outcomes at 30 days (25.9% vs. 9.2%; p < 0.001).

CONCLUSION

At-school out-of-hospital cardiac arrests were rare in France, however demonstrated favourable prognostic features and outcomes. The use of automated external defibrillators in at-school cases, while more common than cases occurring elsewhere, should be improved.

A global perspective on gun violence injuries

INTRODUCTION AND DEFINITIONS

Civilian gunshot violence is a growing public health issue on a global scale. Treatment of patients with gunshot injuries is based on algorithms derived from military studies, but the distinct differences in weaponry, energy of injury, timing and type of care, and environment translate to a gap in knowledge. With a focus on non-accidental gunshot trauma and excluding suicide etiologies, we propose to build a collaborative research group to address important questions focused on best practices for gunshot injury patients.

PRE-HOSPITAL CARE

There are important differences in the care of gunshot victims across the globe; some countries provide advanced interventions in the field and others deliver basic support until transport to a higher level of care in hospital. Some simple interventions include the use of extremity tourniquets and intravenous fluid support; others to consider are tranexamic acid, whole blood, and hemostatic agents.

ACUTE TREATMENT

Control of exsanguinating hemorrhage is a key priority for gunshot injuries. Military doctrine has evolved to prioritize exsanguination over airway or breathing as the critical first step. The X-ABC protocol focuses on exsanguinating hemorrhage, then standard evaluation of Airway, Breathing and Circulation (ABCs) to enhance survival in trauma patients. The timing of bony stabilization, in terms of damage-control vs definitive care, needs further study in this population, as does use of antibiotics for bony extremity injuries. Finally, recognition of the mental health effects of gun trauma, including post-traumatic stress disorder (PTSD), anxiety disorders, substance abuse and depression is important in advocating for prevention such as implementation of social support and specific interventions.

DEFINITIVE CARE

The need for abdominal closure after exploratory laparotomy, definitive fracture treatment, and other treatment all contribute to length of stay for gunshot injured patients. Optimizing stabilization allows earlier mobilization and decreases nosocomial complications. Nerve injuries are often a source of long-term disability and their evaluation and treatment require further investigation.

RESOURCES AND ETHICS

There are growing numbers of mass-casualty gunshot events, which require consideration of how to organize and use resources for treatment, including staff, operating room access, blood products, and order of treatment. Drills and planning for incident command hierarchy and communication are key to optimizing resource utilization. The ethics of choosing treatment priorities and resources are important considerations as well.

Association between out-of-hospital cardiac arrest and survival in paediatric traumatic population: results from the French national registry

Trauma is an important cause of paediatric out-of-hospital cardiac arrest (OHCA) with a high mortality rate. The first aim of this study was to compare the survival rate at day 30 and at hospital discharge following paediatric traumatic and medical OHCA. The second aim was to compare the rates of return of spontaneous circulation and survival rates at hospital admission (Day 0). This multicentre comparative post-hoc study was conducted between July 2011 and February 2022 based on the French National Cardiac Arrest Registry data. All patients aged <18 years with OHCA were included in the study. Patients with traumatic aetiology were matched with those with medical aetiology using propensity score matching. Endpoint was the survival rate at day 30. There were 398 traumatic and 1061 medical OHCAs. Matching yielded 227 pairs. In non-adjusted comparisons, days 0 and 30 survival rates were lower in the traumatic aetiology group than in the medical aetiology group [19.1% vs. 24.0%, odds ratio (OR) 0.75, 95% confidence interval (CI) 0.56-0.99, and 2.0% vs. 4.5%, OR 0.43, 95% CI, 0.20-0.92, respectively]. In adjusted comparisons, day 30 survival rate was lower in the traumatic aetiology group than in the medical aetiology group (2.2% vs. 6.2%, OR 0.36, 95% CI, 0.13-0.99). In this post-hoc analysis, paediatric traumatic OHCA was associated with a lower survival rate than medical cardiac arrest.

Out-of-hospital cardiac arrest in pregnant women: a 55-patient French cohort study

AIM

To describe a cohort of pregnant women having suffered an out-of-hospital cardiac arrest (OHCA) and to compare them with nonpregnant women of childbearing age having suffered OHCA.

METHODS

Study data were extracted from the French National OHCA Registry between 2011 and 2021. We compared patients in terms of characteristics, care and survival.

RESULTS

We included 3,645 women of childbearing age (15-44) who had suffered an OHCA; 55 of the women were pregnant. Pregnant women were younger than nonpregnant victims (30 vs. 35 years, p=0.006) and were more likely to have a medical history (76.4% vs. 50.5%, p<0.001) and a medical cause of the OHCA (85.5% vs. 57.2%, p<0.001). Advanced Life Support was more frequently administered to pregnant women (98.2%, vs. 72.0%; p<0.001). In pregnant women, the median time of MICU arrival was 20 minutes for the Medical Intensive Care Unit with no difference with nonpregnant women. Survival rate on admission to hospital was higher among pregnant women (43.6% vs. 27.3%; p=0.009). There was no difference in 30-day survival between pregnant and nonpregnant groups (14.5% vs. 7.3%; p=0.061). Fetal survival was only observed for OHCAs that occurred during the pregnancy second or third trimester (survival rates: 10.0% and 23.5%, respectively).

CONCLUSIONS

Our results show that resuscitation performance does not meet European Resuscitation Council's specific guidelines on OHCA in pregnant women. Although OHCA in pregnancy is rare, the associated prognosis is poor for both woman and fetus. Preventive measures should be reinforced, especially when pregnant women have medical history.

Effect of sodium bicarbonate on functional outcome in patients with out-of-hospital cardiac arrest: a post-hoc analysis of a French and North-American dataset

BACKGROUND AND IMPORTANCE

No large randomised controlled trial has assessed the potential benefits on neurologic outcomes of prehospital sodium bicarbonate administration in patients with nontraumatic out-of-hospital cardiac arrest (OHCA).

OBJECTIVE

To obtain information of assistance in designing a randomised controlled trial of bicarbonate therapy after OHCA in specific patient subgroups.

DESIGN

We conducted two, separate, simultaneous, retrospective studies of two distinct, unlinked datasets.

SETTING AND PARTICIPANTS

One dataset was a French nationwide population-based registry (RéAC Registry, French dataset) and the other was a randomised controlled trial comparing continuous to interrupted chest compressions in North America (ROC-CCC trial, North-American dataset).

INTERVENTION

We investigated whether prehospital bicarbonate administration was associated with better neurologic outcomes.

OUTCOME MEASURES AND ANALYSES

The main outcome measure was the functional outcome at hospital discharge. To adjust for potential confounders, we conducted a nested propensity-score-matched analysis with inverse probability-of-treatment weighting.

MAIN RESULTS

In the French dataset, of the 54 807 patients, 1234 (2.2%) received sodium bicarbonate and 450 were matched. After propensity-score matching, sodium bicarbonate was not associated with a higher likelihood of favourable functional outcomes on day 30 [adjusted odds ratio (aOR), 0.912; 95% confidence interval (95%CI), 0.501-1.655]. In the North-American dataset, of the 23 711 included patients, 4902 (20.6%) received sodium bicarbonate and 1238 were matched. After propensity-score matching, sodium bicarbonate was associated with a lower likelihood of favourable functional outcomes at hospital discharge (aOR, 0.45; 95% CI, 0.34-0.58).

CONCLUSION

In patients with OHCA, prehospital sodium bicarbonate administration was not associated with neurologic outcomes in a French dataset and was associated with worse neurologic outcomes in a North-American dataset. Given the considerable variability in sodium bicarbonate use by different prehospital care systems and the potential resuscitation-time bias in the present study, a large randomised clinical trial targeting specific patient subgroups may be needed to determine whether sodium bicarbonate has a role in the prehospital management of prolonged OHCA.

Prehospital predictors for return of spontaneous circulation in traumatic cardiac arrest

BACKGROUND

Traumatic cardiac arrests (TCAs) are associated with high mortality and the majority of deaths occur at the prehospital scene. The aim of the present study was to assess, in a prehospital physician-led emergency medical system, the factors associated with sustained return of spontaneous circulation (ROSC) in TCA, including advanced life procedures. The secondary objectives were to assess factors associated with 30-day survival in TCA, evaluate neurological recovery in survivors, and describe the frequency of organ donation among patients experiencing a TCA.

METHODS

We conducted a retrospective study of all TCA patients included in the French nationwide cardiac arrest registry from July 2011 to November 2020. Multivariable logistic regression analysis was used to identify factors independently associated with ROSC.

RESULTS

A total of 120,045 out-of-hospital cardiac arrests were included in the registry, among which 4,922 TCA were eligible for analysis. Return of spontaneous circulation was sustained on-scene in 21.1% (n = 1,037) patients. Factors significantly associated with sustained ROSC were not-asystolic initial rhythms (pulseless electric activity (odds ratio [OR], 1.81; 95% confidence interval [CI], 1.40-2.35; p < 0.001), shockable rhythm (OR, 1.83; 95% CI, 1.12-2.98; p = 0.016), spontaneous activity (OR, 3.66; 95% CI, 2.70-4.96; p < 0.001), and gasping at the mobile medical team (MMT) arrival (OR, 1.40; 95% CI, 1.02-1.94; p = 0.042). The MMT interventions significantly associated with ROSC were as follows: intravenous fluid resuscitation (OR, 3.19; 95% CI, 2.69-3.78; p < 0.001), packed red cells transfusion (OR, 2.54; 95% CI, 1.84-3.51; p < 0.001), and external hemorrhage control (OR, 1.74; 95% CI, 1.31-2.30; p < 0.001). Among patients who survived (n = 67), neurological outcome at Day 30 was favorable (cerebral performance categories 1-2) in 72.2% cases (n = 39/54) and 1.4% (n = 67/4,855) of deceased patients donated one or more organ.

CONCLUSION

Sustained ROSC was frequently achieved in patients not in asystole at MMT arrival, and higher ROSC rates were achieved in patients benefiting from specific advanced life support interventions. Organ donation was somewhat possible in TCA patients undergoing on-scene resuscitation.

LEVEL OF EVIDENCE

Prognostic and epidemiologic, Level III.

Association of dispatcher-assisted cardiopulmonary resuscitation with initial shockable rhythm and survival after out-of-hospital cardiac arrest

BACKGROUND AND IMPORTANCE

Bystander cardiopulmonary resuscitation (CPR) and initial shockable rhythm are crucial predictors of survival after out-of-hospital cardiac arrest (OHCA). However, the relationship between dispatcher-assisted CPR (DA-CPR) and initial shockable rhythm is not completely elucidated.

OBJECTIVE

To examine the association of DA-CPR with initial shockable rhythm and outcomes.

DESIGN, SETTING AND PARTICIPANTS

This nationwide population-based observational study conducted in Japan included 59 688 patients with witnessed OHCA of cardiac origin after excluding those without bystander CPR. Patients were divided into DA-CPR (n = 42 709) and CPR without dispatcher assistance (unassisted CPR, n = 16 979) groups.

OUTCOME MEASURES AND ANALYSIS

The primary outcome measure was initial shockable rhythm, and secondary outcome measures were 1-month survival and neurologically intact survival. A Cox proportional hazards model adjusted for collapse-to-first-rhythm-analysis time and multivariable logistic regression models were used after propensity score (PS) matching to compare the incidence of initial shockable rhythm and outcomes, respectively.

MAIN RESULTS

Among all patients (mean age 76.7 years), the rates of initial shockable rhythm, 1-month survival and neurologically intact survival were 20.8, 10.7 and 7.0%, respectively. The incidence of initial shockable rhythm in the DA-CPR group (20.4%, 3462/16 979) was significantly higher than that in the unassisted CPR group (18.5%, 3133/16 979) after PS matching (P < 0.0001). However, no significant differences were found between the two groups with respect to the incidence of initial shockable rhythm in the Cox proportional hazards model [adjusted hazard ratio of DA-CPR for initial shockable rhythm compared with unassisted CPR, 0.99; 95% confidence interval (CI), 0.97-1.02, P = 0.56]. No significant differences were observed in the survival rates in the two groups after PS matching [10.8% (1833/16 979) vs. 10.3% (1752/16 979), P = 0.16] and neurologically intact survival rates [7.3% (1233/16 979) vs. 6.8% (1161/16 979), P = 0.13]. The multivariable logistic regression model showed no significant differences between the groups with regard to survival (adjusted odds ratio of DA-CPR compared with unassisted CPR: 1.00; 95% CI, 0.89-1.13, P = 0.97) and neurologically intact survival (adjusted odds ratio: 1.12; 95% CI, 0.98-1.29, P = 0.14).

CONCLUSION

DA-CPR after OHCA had the same independent association with the likelihood of initial shockable rhythm and 1-month meaningful outcome as unassisted CPR.

Effect of adrenaline dose on neurological outcome in out-of-hospital cardiac arrest: a nationwide propensity score analysis

BACKGROUND

Adrenaline is recommended during cardio-pulmonary resuscitation. The optimal dose remains debated, and the effect of lower than recommended dose is unknown.

OBJECTIVE

To compare the outcome of patients treated with the recommended, lower or higher cumulative doses of adrenaline.

DESIGN, SETTINGS, PARTICIPANTS

Patients were included from the French National Cardiac Arrest Registry and were grouped based on the received dose of adrenaline: recommended, higher and lower dose.

OUTCOME MEASURES AND ANALYSIS

The primary endpoint was good neurologic outcome at 30 days post-OHCA, defined by a cerebral performance category (CPC) of less than 3. Secondary endpoints included return of spontaneous circulation and survival to hospital discharge. A multiple propensity score adjustment approach was performed.

MAIN RESULTS

27 309 patients included from July 1st 2011 to January 1st 2019 were analysed, mean age was 68 (57-78) years and 11.2% had ventricular fibrillation. 588 (2.2%) patients survived with a good CPC score. After adjustment, patients in the high dose group had a significant lower rate of good neurologic outcome (OR, 0.6; 95% CI, 0.5-0.7). There was no significant difference for the primary endpoint in the lower dose group (OR, 0.8; 95% CI, 0.7-1.1). There was a lower rate of survival to hospital discharge in the high-dose group vs. standard group (OR, 0.5; 95% CI, 0.5-0.6).

CONCLUSION

The use of lower doses of adrenaline was not associated with a significant difference on survival good neurologic outcomes at D30. But a higher dose of adrenaline was associated with a lower rate of survival with good neurological outcomes and poorer survival at D30.

Régulation médicale de la dyspnée de l’enfant : intérêt d’une régulation pédiatrique

Introduction :L’évaluation téléphonique du patient pédiatrique peut être difficile à la régulation médicale du Samu-Centre 15 (aide médicale urgente [AMU] ou permanence de soins [PDS]). La dyspnée est un motif d’appel fréquent dans cette population et présente des particularités importantes comparée à la population adulte. Nous avons voulu évaluer la pertinence de l’évaluation téléphonique de la dyspnée en pédiatrie selon la qualification du médecin régulateur (urgentiste, généraliste ou pédiatre).

Matériel et méthode :Il s’agit d’une étude observationnelle rétrospective monocentrique menée au Samu de Haute-Garonne entre le 1er décembre 2018 au 31 janvier 2019. Les critères d’inclusion étaient un appel pour tout patient avec un âge inférieur à dix ans pour dyspnée. Le critère de jugement principal était le surtriage.

Résultats : Nous avons analysé 717 appels pour dyspnée pédiatrique sur la période. La non-adéquation entre la décision médicale et le devenir du patient était retrouvée chez 174 patients (24 %) : 173 patients (99 %) étaient surtriés et un patient était sous-trié (< 1 %). En analyse multivariée, les facteurs protecteurs de surtriage étaient l’âge de six mois à trois ans (OR = 0,56 ; IC 95 % = [0,36–0,86]) comparé à un âge jeune (≤ 6 mois ; référence) et l’évaluation par un régulateur de PDS (OR = 0,38 ; IC 95 % = [0,23–0,62]) ou pédiatre (OR = 0,54 ; IC 95 % = [0,34–0,86]) comparé à un régulateur de l’AMU (référence). L’appel nocturne était un facteur de risque de surtriage (OR = 1,98 ; IC 95 % = [1,39–2,84]).

Conclusion : La régulation par un pédiatre ou un médecin de la PDS permet de réduire le surtriage dans un centre où les régulateurs AMU n’ont pas d’activité pédiatrique clinique.

High dose of epinephrine does not improve survival of children with out-of-hospital cardiac arrest: Results from the French National Cardiac Arrest Registry

OBJECTIVES

The pediatric resuscitation guidelines recommend the use of 0. 01 mg kg^-1 epinephrine during a cardiac arrest; an epinephrine dose higher than that is not recommended. The first aim of this study was to determine the administration rate of high epinephrine dose during pediatric out-of-hospital cardiac arrest. The second aim was to compare the survival status in patients who received high or standard doses of epinephrine.

METHODS

This was a multicenter comparative post-hoc study conducted between January 2011 and July 2021 based on the French National Cardiac Arrest Registry data. All prepubescent (boys < 12 years old, girls < 10 years old) victims of an out-of-hospital cardiac arrest were included. To compare survival status and control bias, patients who received a high epinephrine dose were matched with those who received a standard epinephrine dose using propensity score matching.

RESULTS

The analysis included 755 patients; 400 (53%) received a high dose and 355 (47%) received a standard dose of epinephrine. The median dose (mg kg^-1) per bolus was higher in the high-dose group than that in the standard dose group (0.04 vs. 0.01 mg kg^-1, P < 0.001). Before matching, there was no between-group difference in the 30-day survival rate or survival status at hospital discharge. Matching yielded 288 pairs; there was no between-group difference in the 30-day survival rate or survival at hospital discharge (High dose, n = 5; standard dose, n = 12; Odds ratios: 2.40, 95% confidence interval: 0.85-6.81). Only 2 patients in the standard dose group had a good neurological outcome.

CONCLUSION

More than 50% of the patients did not receive the recommended epinephrine dose during resuscitation. There was no association between patients receiving a high dose or standard dose of epinephrine with the 30-day survival or survival status at hospital discharge. Collaboration across multiple cardiac arrest registries is needed to study the application of pediatric guidelines.

Coronavirus Disease 2019 and Out-of-Hospital Cardiac Arrest: No Survivors

To describe and compare survival among patients with out-of-hospital cardiac arrest as a function of their status for coronavirus disease 2019.

Community emergency medicine throughout the UK and Ireland: a comparison of current national activity

BACKGROUND

Community emergency medicine (CEM) aims to bring highly skilled, expert medical care to the patient outside of the traditional ED setting. Currently, there are several different CEM models in existence within the UK and Ireland which confer multiple benefits including provision of a senior clinical decision-maker early in the patient's journey, frontloading of time-critical interventions, easing pressure on busy EDs and reducing inpatient bed days. This is achieved through increased community-based management supplemented by utilisation of alternative care pathways. This study aimed to undertake a national comparison of CEM services currently in operation.

METHOD

A data collection tool was distributed to CEM services by the Pre-Hospital trainee Operated Research Network in October 2020 which aimed to establish current practice among services in the UK and Ireland. It focused on six key sections: service aims; staffing and training; job tasking and patient selection; funding and vehicles used; equipment and medication; data collection, governance and research activity.

RESULTS

Seven services responded from across England, Wales and Ireland. Similarities were found with the aims of each service, staffing structures and operational times. There were large differences in equipment carried, categories of patient targeted and with governance and research activity.

CONCLUSION

While some national variations in services are explained by funding and geographical location, this review process revealed several differences in practice under the umbrella term of CEM. A national definition of CEM and its aim, with guidance on scope of practice and measurable outcomes, should be generated to ensure high standard and cost-effective emergency care is delivered in the community.

Endotracheal intubation versus supraglottic procedure in paediatric out-of-hospital cardiac arrest: a registry-based study

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) in children is associated with a low survival rate. Conclusions in the literature are conflicting regarding the best way to handle ventilation. The purpose of this study was to assess the impact of two airway management strategies, endotracheal intubation (ETI) vs. supraglottic procedure, during cardiopulmonary resuscitation (CPR) on 30-day survival in paediatric OHCA.

METHODS

This was a retrospective, observational, multicentre, registry-based study conducted from July 2011 to March 2018. All paediatric OHCA patients under 18 years of age and managed by a mobile intensive care unit were included. The primary endpoint was 30-day survival in a weighted population (based on propensity scores).

RESULTS

Of 1579 children, 1355 (85.8%) received ETI and 224 (14.2%) received supraglottic ventilation during CPR. We observe a lower 30-day survival in the ETI group compared to the supraglottic group (7.7% vs. 14.3%, absolute difference, 6.6 percentage points; 95% confidence interval [CI], 2.3-12.0; propensity-adjusted odds ratio [paOR], 0.39; 95% CI, 0.25-0.62; p < 0.001), and also a poorer neurological outcome (paOR, 0.32; 95% CI, 0.19-0.54; p < 0.001). However, we did not identify any significant association between airway management strategy and return of spontaneous circulation (paOR, 1.15; 95% CI, 0.80-1.65; p = 0.46).

CONCLUSIONS

The findings of this large cohort study suggest that ETI in paediatric OHCA, although performed by trained physicians, is associated with a worse outcome, regardless of traumatic or non-traumatic aetiology.

Factors Influencing Physician Decision Making to Attempt Advanced Resuscitation in Asystolic Out-of-Hospital Cardiac Arrest

The objective of this study was to identify the key elements used by prehospital emergency physicians (EP) to decide whether or not to attempt advanced life support (ALS) in asystolic out-of-hospital cardiac arrest (OHCA). From 1 January 2009 to 1 January 2017, all adult victims of asystolic OHCA in Geneva, Switzerland, were retrospectively included. Patients with signs of “obvious death” or with a Do-Not-Attempt-Resuscitation order were excluded. Patients were categorized as having received ALS if this was mentioned in the medical record, or, failing that, if at least one dose of adrenaline had been administered during cardiopulmonary resuscitation (CPR). Prognostic factors known at the time of EP’s decision were included in a multivariable logistic regression model. Included were 784 patients. Factors favourably influencing the decision to provide ALS were witnessed OHCA (OR = 2.14, 95% CI: 1.43–3.20) and bystander CPR (OR = 4.10, 95% CI: 2.28–7.39). Traumatic aetiology (OR = 0.04, 95% CI: 0.02–0.08), age > 80 years (OR = 0.14, 95% CI: 0.09–0.24) and a Charlson comorbidity index greater than 5 (OR = 0.12, 95% CI: 0.06–0.27) were the factors most strongly associated with the decision not to attempt ALS. Factors influencing the EP’s decision to attempt ALS in asystolic OHCA are the relatively young age of the patients, few comorbidities, presumed medical aetiology, witnessed OHCA and bystander CPR.

Assessment of changes in cardiopulmonary resuscitation practices and outcomes on 1005 victims of out-of-hospital cardiac arrest during the COVID-19 outbreak: registry-based study

Background

The COVID-19 outbreak requires a permanent adaptation of practices. Cardiopulmonary resuscitation (CPR) is also involved and we evaluated these changes in the management of out-of-hospital cardiac arrest (OHCA).

Methods

OHCA of medical origins identified from the French National Cardiac Arrest Registry between March 1st and April 31st 2020 (COVID-19 period), were analysed. Different resuscitation characteristics were compared with the same period from the previous year (non-COVID-19 period).

Results

Overall, 1005 OHCA during the COVID-19 period and 1620 during the non-COVID-19 period were compared. During the COVID-19 period, bystanders and first aid providers initiated CPR less frequently (49.8% versus 54.9%; difference, − 5.1 percentage points [95% CI, − 9.1 to − 1.2]; and 84.3% vs. 88.7%; difference, − 4.4 percentage points [95% CI, − 7.1 to − 1.6]; respectively) as did mobile medical teams (67.3% vs. 75.0%; difference, − 7.7 percentage points [95% CI, − 11.3 to − 4.1]). First aid providers used defibrillators less often (66.0% vs. 74.1%; difference, − 8.2 percentage points [95% CI, − 11.8 to − 4.6]). Return of spontaneous circulation (ROSC) and D30 survival were lower during the COVID-19 period (19.5% vs. 25.3%; difference, − 5.8 percentage points [95% CI, − 9.0 to − 2.5]; and 2.8% vs. 6.4%; difference, − 3.6 percentage points [95% CI, − 5.2 to − 1.9]; respectively).

Conclusions

During the COVID-19 period, we observed a decrease in CPR initiation regardless of whether patients were suspected of SARS-CoV-2 infection or not. In the current atmosphere, it is important to communicate good resuscitation practices to avoid drastic and lasting reductions in survival rates after an OHCA.

Neurological Outcome of Chest Compression-Only Bystander CPR in Asphyxial and Non-Asphyxial Out-Of-Hospital Cardiac Arrest: An Observational Study

Background: According to guidelines and bystander skill, two different methods of cardiopulmonary resuscitation (CPR) are feasible: standard CPR (S-CPR) with mouth-to-mouth ventilations and chest compression-only CPR (CO-CPR) without rescue breathing. CO-CPR appears to be most effective for cardiac causes, but there is a lack of evidence for asphyxial causes of out-of-hospital cardiac arrest (OHCA). Thus, the aim of our study was to compare CO-CPR versus S-CPR in adult OHCA from medical etiologies and assess neurologic outcome in asphyxial and non-asphyxial causes.Methods: Using the French National OHCA Registry (RéAC), we performed a multicenter retrospective study over a five-year period (2013 to 2017). All adult-witnessed OHCA who had benefited from either S-CPR or CO-CPR by bystanders were included. Non-medical causes as well as professional rescuers as witnesses were excluded. The primary end point was 30-day neurological outcome in a weighted population for all medical causes, and then for asphyxial, non-asphyxial and cardiac causes.Results: Of the 8 541 subjects included for all medical causes, 6 742 had a non-asphyxial etiology, including 5 904 of cardiac causes, and 1 799 had an asphyxial OHCA. Among all subjects, 8.6%; 95% CI [8.1-9.3] had a good neurological outcome (i.e. cerebral performance category of 1 or 2). Bystanders who performed S-CPR began more often immediately (89.0%; 95% CI [87.3-90.5] versus 78.2%; 95% CI [77.2-79.2]) and in younger subjects (64.1 years versus 65.7; p < 0.001). In the weighted population, subjects receiving bystander-initiated CO-CPR had an adjusted relative risk (aRR) of 1.04; 95% CI [0.79-1.38] of having a good neurological outcome at 30 days for all medical causes, 1.28; 95% CI [0.92-1.77] for asphyxial etiologies, 1.08; 95% CI [0.80-1.46] for non-asphyxial etiologies and 1.09; 95% CI [0.93-1.28] for cardiac-related OHCA.Conclusions: We observed no significant difference in neurological outcome when lay bystanders of adult OHCA initiated CO-CPR or S-CPR, whether the cause was asphyxial or not.

Symptom-Based Dispatching in an Emergency Medical Communication Centre: Sensitivity, Specificity, and the Area under the ROC Curve

Measuring the performance of emergency medical dispatch tools used in paramedic-staffed emergency medical communication centres (EMCCs) is rarely performed. The objectives of our study were, therefore, to measure the performance and accuracy of Geneva's dispatch system based on symptom assessment, in particular, the performance of ambulance dispatching with lights and sirens (L&S) and to measure the effect of adding specific protocols for each symptom. Methods: We performed a prospective observational study including all emergency calls received at Geneva's EMCC (Switzerland) from 1 January 2014 to 1 July 2019. The risk levels selected during the emergency calls were compared to a reference standard, based on the National Advisory Committee for Aeronautics (NACA) scale, dichotomized to severe patient condition (NACA ≥ 4) or stable patient condition (NACA < 4) in the field. The symptom-based dispatch performance was assessed using a receiver operating characteristic (ROC) curve. Contingency tables and a Fagan nomogram were used to measure the performance of the dispatch with or without L&S. Measurements were carried out by symptom, and a group of symptoms with specific protocols was compared to a group without specific protocols. Results: We found an acceptable area under the ROC curve of 0.7474, 95%CI (0.7448-0.7503) for the 148,979 assessments included in the study. Where the severity prevalence was 21%, 95%CI (20.8-21.2). The sensitivity of the L&S dispatch was 87.5%, 95%CI (87.1-87.8); and the specificity was 47.3%, 95%CI (47.0-47.6). When symptom-specific assessment protocols were used, the accuracy of the assessments was slightly improved. Conclusions: Performance measurement of Geneva's symptom-based dispatch system using standard diagnostic test performance measurement tools was possible. The performance was found to be comparable to other emergency medical dispatch systems using the same reference standard. However, the implementation of specific assessment protocols for each symptom may improve the accuracy of symptom-based dispatch systems.