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

Immediate care of out-of-hospital cardiac arrest (CA) is standardized by the established ILCOR ACLS Guidelines. Studies concerning the impact of thrombolysis, generally for CA of cardiac etiology have not shown a benefit. We sought to evaluate the rate of hospital admission for all CA patients treated with pre-hospital thrombolytics. Methods: Non-randomized retrospective study was conducted from 09/1/2005 to 02/15/2007 of non-traumatic CA patients treated with (T+) or without (T-) thrombolysis. The protocol for administration of thrombolytics was at the discretion of the field physician, aiming for within 20 minutes of collapse in almost all cases, and prior to return of spontaneous circulation. The primary endpoint was admission alive to the hospital. We performed multivariate analysis by logistic regression to identify risk factors independently associated with outcome: age, gender, response time, defibrillation, witnessed arrest, bystander CPR. Results: We reviewed 1331 consecutive patient records, of which 116 (8.7%) received thrombolytics. Both T+ and T- groups had comparable response times, witnessed arrest, and bystander CPR. Patients in T+ were significantly younger (59±14 vs 67±19 years old), predominantly males (81% vs 61%), and received more defibrillation shocks (61% vs 26 %). Significantly more patients T+ arrived alive to hospital for admission (45% vs 24%). Risk factors independently associated with hospital admissions were thrombolysis, age, response time, witnessed arrest, and bystander CPR. The impact of thrombolysis was different whether or not the patient was defibrillated (odds ratio with shocks 1.1 [95%CI: 0.2–5.0] vs without shocks 3.6 [95%CI: 1.9 – 6.9]), despite a greater overall rate of hospital admission for shocked patients. Conclusion: Thrombolysis appears to improve the rate of admission alive to the hospital in patients that were not defibrillated with adjustment for age, gender, response time, witnessed arrest, and bystander CPR. These preliminary results should be confirmed by a prospective randomized study. This analysis can help determine appropriate inclusion criteria for a future study.

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Out of Hospital Cardiac Arrest Management by First Responders: Retrospective Review of a Fire Fighter First Responder Program

Australasian Journal of Paramedicine ◽

10.33151/ajp.11.5.59 ◽

2014 ◽

Vol 11 (5) ◽

Cited By ~ 1

Author(s):

Christian Winship ◽

Malcolm Boyle ◽

Brett Williams

Keyword(s):

Cardiac Arrest ◽

Response Times ◽

Significant Rise ◽

First Responder ◽

Median Response ◽

Fire Fighters ◽

Shockable Rhythm ◽

Medical Response ◽

Bystander Cpr ◽

Hospital Cardiac Arrest

IntroductionOver 9,500 people die annually in Australia from sudden cardiac arrest, with strong evidence suggesting early high quality CPR and early counter shock being paramount for improving survival from cardiac arrest. It has also been shown that first responder programs have been able to reduce response times and increase survival rates for out-of-hospital cardiac arrest. The objective of this study was to examine data from the first seven years of an Australian out-of-hospital cardiac arrest first responder program where fire fighters provided basic life support.MethodsThis study was a retrospective cohort study of all cardiac arrests attended by the Metropolitan Fire and Emergency Services Board (MFESB) as part of the Emergency Medical Response program over a seven-year period in Melbourne, Victoria, Australia.ResultsThe MFESB attended 4,450 cardiac arrests. The majority of patients presented in asystole 669 (63.7%) with just 243 (23.1%) presenting in a shockable rhythm. The majority of patients in cardiac arrest were males (64.2%) and the mean age of the patients was 67.5 years. The MFESB median response time during the study period was 5.7 minutes (IQR 2.25 minutes), range of 0.15 minutes to 31.7 minutes, which remained stable over the seven years. Patients spent a median time of 4.6 minutes (0.02 seconds to 36.5 minutes) in the care of fire fighters prior to the arrival of EMS. The rhythm on handover to paramedics was asystole in 787 (75.1%) cases with no shockable rhythms. One in three (31.3%) patients received bystander CPR, with a significant rise in the rate of bystander CPR occurring over the last two years.ConclusionThis study demonstrated acceptable response times to cardiac arrests and a low bystander CPR rate prior to arrival of the MFESB. The incidence of a shockable rhythm on arrival of the MFESB was low with the main rhythm being asystole. The main rhythm on handover to paramedics was asystole with non-shockable rhythms. Further research is required to determine the effect on patient outcomes.

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LO72: Implementation of an educational program to improve the cardiac arrest diagnostic accuracy of ambulance communication officers: a concurrent control before-after study

CJEM ◽

10.1017/cem.2017.134 ◽

2017 ◽

Vol 19 (S1) ◽

pp. S52-S53

Author(s):

C. Vaillancourt ◽

A. Kasaboski ◽

M. Charette ◽

L. Calder ◽

L. Boyle ◽

...

Keyword(s):

Cardiac Arrest ◽

Educational Program ◽

Survival Rates ◽

Control Site ◽

Chi Square ◽

Concurrent Control ◽

Initial Rhythm ◽

Bystander Cpr ◽

The Impact ◽

Hospital Cardiac Arrest

Introduction: Most ambulance communication officers receive minimal education on agonal breathing, often leading to unrecognized out-of-hospital cardiac arrest (OHCA). We sought to evaluate the impact of an educational program on cardiac arrest recognition, and on bystander CPR and survival rates. Methods: Ambulance communication officers in Ottawa, Canada received additional training on agonal breathing, while the control site (Windsor, Canada) did not. Sites were compared to their pre-study performance (before-after design), and to each other (concurrent control). Trained investigators used a piloted-standardized data collection tool when reviewing the recordings for all potential OHCA cases submitted. OHCA was confirmed using our local OHCA registry, and we requested 9-1-1 recordings for OHCA cases not initially suspected. Two independent investigators reviewed medical records for non-OHCA cases receiving telephone-assisted CPR in Ottawa. We present descriptive and chi-square statistics. Results: There were 988 confirmed and suspected OHCA in the “before” (540 Ottawa; 448 Windsor), and 1,076 in the “after” group (689 Ottawa; 387 Windsor). Characteristics of “after” group OHCA patients were: mean age (68.1 Ottawa, 68.2 Windsor); Male (68.5% Ottawa, 64.8% Windsor); witnessed (45.0% Ottawa, 41.9% Windsor); and initial rhythm VF/VT (Ottawa 28.9, Windsor 22.5%). Before-after comparisons were: for cardiac arrest recognition (from 65.4% to 71.9% in Ottawa p=0.03; from 70.9% to 74.1% in Windsor p=0.37); for bystander CPR rates (from 23.0% to 35.9% in Ottawa p=0.0001; from 28.2% to 39.4% in Windsor p=0.001); and for survival to hospital discharge (from 4.1% to 12.5% in Ottawa p=0.001; from 3.9% to 6.9% in Windsor p=0.03). “After” group comparisons between Ottawa and Windsor (control) were not statistically different, except survival (p=0.02). Agonal breathing was common (25.6% Ottawa, 22.4% Windsor) and present in 18.5% of missed cases (15.8% Ottawa, 22.2% Windsor p=0.27). In Ottawa, 31 patients not in OHCA received chest compressions resulting from telephone-assisted CPR instructions. None suffered injury or adverse effects. Conclusion: While all OHCA outcomes improved over time, the educational intervention significantly improved OHCA recognition in Ottawa, and appeared to mitigate the impact of agonal breathing.

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P4169The crucial role of the bystander in out-of-hospital cardiac arrest resuscitation

European Heart Journal ◽

10.1093/eurheartj/ehz745.0740 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

T Campos ◽

V Baert ◽

H Hubert ◽

E Wiel ◽

N Benameur

Keyword(s):

Cardiac Arrest ◽

Survival Rate ◽

Survival Data ◽

Health Concern ◽

Propensity Analysis ◽

Bystander Cardiopulmonary Resuscitation ◽

Bystander Cpr ◽

The Impact ◽

Hospital Cardiac Arrest

Abstract Background Out-of-hospital cardiac arrest (OHCA) is a major public health concern in France, given that there are 61.5 cases per 100,000 inhabitants a year. The impact of bystander action, performed before the arrival of emergency medical services (EMS), on survival has never been studied in France. Purpose Determine whether bystander cardiopulmonary resuscitation (CPR), performed before the arrival of EMS, was correlated with an increased 30-day survival rate after an OHCA. Methods 24,885 out-of-hospital cardiac arrests witnessed in France from 1 January 2012 to 1 May 2018 were analysed to determine whether CPR, performed before the arrival of EMS, was correlated with survival. Data from the Electronic Registry of Cardiac Arrests was used. The association between the effect of CPR performed before the arrival of EMS and 30-day survival rate was studied, using propensity analysis (which included variables such as age and sex of the patient, location, cause, and year of cardiac arrest, initial cardiac rhythm, EMS response time and no-flow time). Results CPR was performed before the arrival of EMS in 14,904 cases (59.9%) and was not performed in 9,981 cases (40.1%). The 30-day survival rate was 10.2% when CRP was performed by bystanders versus 3.9% when CRP was not performed before the EMS arrival (p<0.001). CPR performed by bystanders was associated with an increased 30-day survival rate (odds ratio 1.269; 1.207 to 1.334). The effect of bystander CPR on survival Conclusion Bystander CPR performed before the arrival of EMS was associated with an increased 30-day survival rate after an out-of-hospital cardiac arrest in France.

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Community first response and out-of-hospital cardiac arrest: a qualitative study of the views and experiences of international experts

BMJ Open ◽

10.1136/bmjopen-2020-042307 ◽

2021 ◽

Vol 11 (3) ◽

pp. e042307

Author(s):

Eithne Heffernan ◽

Jenny Mc Sharry ◽

Andrew Murphy ◽

Tomás Barry ◽

Conor Deasy ◽

...

Keyword(s):

Cardiac Arrest ◽

Qualitative Study ◽

Response Times ◽

Well Being ◽

Future Research ◽

First Response ◽

Beneficial Impact ◽

Past Experiences ◽

International Experts ◽

The Impact

ObjectivesThis research aimed to examine the perspectives, experiences and practices of international experts in community first response: an intervention that entails the mobilisation of volunteers by the emergency medical services to respond to prehospital medical emergencies, particularly cardiac arrests, in their locality.DesignThis was a qualitative study in which semistructured interviews were conducted via teleconferencing. The data were analysed in accordance with an established thematic analysis procedure.SettingThere were participants from 11 countries: UK, USA, Canada, Australia, New Zealand, Singapore, Ireland, Norway, Sweden, Denmark and the Netherlands.ParticipantsSixteen individuals who held academic, clinical or managerial roles in the field of community first response were recruited. Maximum variation sampling targeted individuals who varied in terms of gender, occupation and country of employment. There were eight men and eight women. They included ambulance service chief executives, community first response programme managers and cardiac arrest registry managers.ResultsThe findings provided insights on motivating and supporting community first response volunteers, as well as the impact of this intervention. First, volunteers can be motivated by ‘bottom-up factors’, particularly their characteristics or past experiences, as well as ‘top-down factors’, including culture and legislation. Second, providing ongoing support, especially feedback and psychological services, is considered important for maintaining volunteer well-being and engagement. Third, community first response can have a beneficial impact that extends not only to patients but also to their family, their community and to the volunteers themselves.ConclusionsThe findings can inform the future development of community first response programmes, especially in terms of volunteer recruitment, training and support. The results also have implications for future research by highlighting that this intervention has important outcomes, beyond response times and patient survival, which should be measured, including the benefits for families, communities and volunteers.

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Abstract 19131: The Advanced Life Support Termination of Resuscitation Rule: A Local Evaluation of the Impact on Termination Rates

Circulation ◽

10.1161/circ.132.suppl_3.19131 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Joris Nas ◽

Judith L Bonnes ◽

Dominique V Verhaert ◽

Wessel Keuper ◽

Pierre van Grunsven ◽

...

Keyword(s):

Life Support ◽

Response Times ◽

Advanced Life Support ◽

Spontaneous Circulation ◽

Shock Delivery ◽

Bystander Cardiopulmonary Resuscitation ◽

Initial Rhythm ◽

Bystander Cpr ◽

The Impact ◽

Termination Decisions

Introduction: Termination of Resuscitation (TOR) rules have been designed to guide in-field termination decisions and reduce futile hospital transportations. The impact of such a rule may depend on regional infrastructure, arrest characteristics and pre-existent termination rates. Our region is characterized by high rates of bystander cardiopulmonary resuscitation (CPR), and Advanced Life Support (ALS) trained rescuers authorized to make termination decisions. We aim to investigate the actual in-field termination rates and the termination rates as recommended by the ALS-TOR rule. Furthermore, we studied factors associated with the actual termination decisions. Methods: Cohort of out-of-hospital cardiac arrest patients who were resuscitated in the Nijmegen area, the Netherlands (2008-2011). The ALS-TOR rule recommends termination in case all following criteria are met: unwitnessed arrest, no bystander CPR, no shock delivery, no return of spontaneous circulation (ROSC). Results: The observed percentage of in-field termination was 46% (275/598), while the ALS-TOR rule recommended termination in only 6% (35/588), owing to high percentages of witnessed arrests (73%) and bystander CPR (54%) in our region. Factors independently associated with the actual decisions to terminate resuscitation were absence of ROSC [aOR 35.6 (95% CI 18.3-69.3)], non-shockable initial rhythm [aOR 6.0 (95% CI 3.2-11.0)], unwitnessed arrest [aOR 2.7 (95% CI 1.4-5.2)], non-public arrest [aOR 2.5 (95% CI 1.2-5.0)] and longer EMS-response times [aOR 1.1 per minute increase (95% CI 1.0-1.2)]. Conclusions: Contrary to previous studies, implementation of the ALS-TOR rule in our region would have decreased termination rates from almost half to less than 10% due to the favourable arrest characteristics. In light of the prognosis after OHCA, this finding suggests that adherence to this set of criteria does not contribute to efficient triage in our population. Therefore it seems prudent to locally evaluate the utility of the ALS-TOR rule prior to implementation.

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Out-of-Hospital Cardiac Arrest—Review of Demographics in South Australia to Inform Decisions about the Provision of Automatic External Defibrillators within the Community

Prehospital and Disaster Medicine ◽

10.1017/s1049023x00008700 ◽

2010 ◽

Vol 25 (6) ◽

pp. 521-526 ◽

Cited By ~ 3

Author(s):

Kathryn Zeitz ◽

Hugh Grantham ◽

Robert Elliot ◽

Chris Zeitz

Keyword(s):

Cardiac Arrest ◽

South Australia ◽

Mean Value ◽

Public Access ◽

Ambulance Service ◽

Case Review ◽

Retrospective Case ◽

Bystander Cpr ◽

The Impact ◽

Hospital Cardiac Arrest

AbstractIntroduction:Sudden, out-of-hospital cardiac arrest (OHCA) has an annual incidence of approximately 50 per 100,000 population. Public access defibrillation is seen as one of the key strategies in the chain-of-survival for OHCA. Positioning of these devices is important for the maximization of public health outcomes. The literature strongly advocates widespread public access to automated external defibrillatiors (AEDs). The most efficient placement of AEDs within individual communities remains unclear.Methods:A retrospective case review of OHCAs attended by the South Australia Ambulance Service in metropolitan and rural South Australia over a 30-month period was performed. Data were analyzed using Utstein-type indicators. Detailed demographics, summative data, and clinical data were recorded.Results:A total of 1,305 cases of cardiac arrest were reviewed. The annual rate of OHCA was 35 per 100,000 population. Of the cases, the mean value for the ages was 66.3 years, 517 (39.6%) were transported to hospital, 761 (58.3%) were judged by the paramedic to be cardiac, and 838 (64.2%) were witnessed. Bystander cardiopulmonary resuscitation (CPR) was performed in 495 (37.9%) of cases. The rhythm on arrival was ventricular fibrillation (VF) or ventricular tachycardia (VT) in 419 (32.1%) cases, and 315 (24.1%) of all arrests had return of spontaneous circulation (ROSC) before or on arrival at the hospital. For cardiac arrest cases that were witnessed by the ambulance service (n = 121), the incidence of ROSC was 47.1%.During the 30-month period, there only was one location that recorded more than one cardiac arrest. No other location recorded recurrent episodes.Conclusions:This study did not identify any specific location that would justify defibrillator placement over any other location without an existing defibrillator. The impact of bystander CPR and the relatively low rate of bystander CPR in this study points to an area of need. The relative potential impact of increasing bystander CPR rates versus investing in defibrillators in the community is worthy of further consideration.

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Protocol for a cohort study of the impact of the COVID-19 pandemic on the rate and incidence of bystander cardiopulmonary resuscitation (CPR) after out-of-hospital cardiac arrest

Scandinavian Journal of Trauma Resuscitation and Emergency Medicine ◽

10.1186/s13049-021-00890-6 ◽

2021 ◽

Vol 29 (1) ◽

Author(s):

Ingvild B. M. Tjelmeland ◽

Jan Wnent ◽

Siobhan Masterson ◽

Jo Kramer-Johansen ◽

Jan-Thorsten Gräsner

Keyword(s):

Cardiac Arrest ◽

Cohort Study ◽

Cardiopulmonary Resuscitation ◽

Early Recognition ◽

Aggregated Data ◽

General Data Protection Regulation ◽

Number Of Patients ◽

Bystander Cpr ◽

The Impact ◽

Hospital Cardiac Arrest

Abstract Background Survival after out-of-hospital cardiac arrest (OHCA) is dependent on early recognition, early cardiopulmonary resuscitation (CPR) and early defibrillation. The purpose of CPR is to maintain some blood flow until the arrival of the emergency medical services (EMS). Our concern is that the COVID-19 pandemic has had a negative effect on the number of patients who get CPR before EMS arrival. The aim of this study is to compare the incidence of bystander CPR during the pandemic with data from before the pandemic. Methods The protocol is for a retrospective cohort study where data from existing registries will be used. All participating registries will share aggregated data from 2017 to 2020, and the study team will compare the results from 2020 to results from 2017 to 2019. Due to the General Data Protection Regulation, each participating registry will check for completeness and plausibility, and perform all aggregation of data locally. In the following analysis different registries will be considered as random samples and analysed by means of a generalized linear mixed effects model with Poisson distribution for the outcome, the population covered as offsets, and different registries as random factors. Discussion This study does not present the prospect of direct benefit to the patient, but does provide an opportunity to gain a better understanding of the epidemiology of bystander CPR for OHCA patients during a pandemic. By comparing data during the pandemic with already collected information in established registries we believe we can gain valuable information about changes in public response to out-of-hospital cardiac arrest.

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Response Time Threshold for Predicting Outcomes of Patients with Out-of-Hospital Cardiac Arrest

Emergency Medicine International ◽

10.1155/2021/5564885 ◽

2021 ◽

Vol 2021 ◽

pp. 1-6

Author(s):

Ling Hsuan Huang ◽

Yu-Ni Ho ◽

Ming-Ta Tsai ◽

Wei-Ting Wu ◽

Fu-Jen Cheng

Keyword(s):

Cardiac Arrest ◽

Response Time ◽

Hospital Discharge ◽

Youden Index ◽

Roc Curve Analysis ◽

Optimal Response ◽

Time Threshold ◽

Bystander Cpr ◽

The Impact ◽

Hospital Cardiac Arrest

Ambulance response time is a prognostic factor for out-of-hospital cardiac arrest (OHCA), but the impact of ambulance response time under different situations remains unclear. We evaluated the threshold of ambulance response time for predicting survival to hospital discharge for patients with OHCA. A retrospective observational analysis was conducted using the emergency medical service (EMS) database (January 2015 to December 2019). Prehospital factors, underlying diseases, and OHCA outcomes were assessed. Receiver operating characteristic (ROC) curve analysis with Youden Index was performed to calculate optimal cut-off values for ambulance response time that predicted survival to hospital discharge. In all, 6742 cases of adult OHCA were analyzed. After adjustment for confounding factors, age (odds ratio [OR] = 0.983, 95% confidence interval [CI]: 0.975–0.992, p < 0.001 ), witness (OR = 3.022, 95% CI: 2.014–4.534, p < 0.001 ), public location (OR = 2.797, 95% CI: 2.062–3.793, p < 0.001 ), bystander cardiopulmonary resuscitation (CPR, OR = 1.363, 95% CI: 1.009–1.841, p = 0.044 ), EMT-paramedic response (EMT-P, OR = 1.713, 95% CI: 1.282–2.290, p < 0.001 ), and prehospital defibrillation using an automated external defibrillator ([AED] OR = 3.984, 95% CI: 2.920–5.435, p < 0.001 ) were statistically and significantly associated with survival to hospital discharge. The cut-off value was 6.2 min. If the location of OHCA was a public place or bystander CPR was provided, the threshold was prolonged to 7.2 min and 6.3 min, respectively. In the absence of a witness, EMT-P, or AED, the threshold was reduced to 4.2, 5, and 5 min, respectively. The adjusted OR of EMS response time for survival to hospital discharge was 1.217 (per minute shorter, CI: 1.140–1299, p < 0.001 ) and 1.992 (<6.2 min, 95% CI: 1.496–2.653, p < 0.001 ). The optimal response time threshold for survival to hospital discharge was 6.2 min. In the case of OHCA in public areas or with bystander CPR, the threshold was prolonged, and without witness, the optimal response time threshold was shortened.

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