This study aimed at evaluating two emergency medical service systems, one in which emergency life-saving technicians (ELSTs) are allowed to administer epinephrine (adrenaline) to patients with out-of-hospital cardiac arrest and one in which ELSTs are allowed to administer epinephrine, lidocaine, and atropine.
A modified, prospective community health trial was conducted from April 1 to October 31, 2003. Areas served by physician-manned ambulances, where out-of-hospital cardiopulmonary resuscitation (CPR) was performed with resuscitative drugs (experimental areas), were compared to areas served by ELST-manned ambulances, where resuscitative drugs were not administered outside the hospital (reference areas). The sequence of emergency procedures performed in the experimental areas was divided into three phases. Phase I included administration of epinephrine, which simulated administration of epinephrine by ELSTs. Phase II started with the use of lidocaine or atropine. Phases I and II simulated administration of epinephrine, lidocaine, and atropine by ELSTs. Phase III began with administration of another drug. Outcomes, resuscitation rates and 1-month survival rates were determined, and differences between the two types of areas were analyzed.
For non-traumatic cardiac arrest, outcomes through phase II in the experimental areas were significantly better than those in the reference areas. Phase I-only outcomes in the experimental areas were better, but not significantly better, than those in the reference areas.
Use of resuscitative drugs for non-traumatic prehospital CPR appears to be effective in terms of resuscitation rates and 1-month survival rates.
"Ohshige and colleagues conducted a similar observational study comparing regions in Japan where emergency medical system services were either manned by emergency life-saving technicians (unable to administer resuscitative drugs at the time), or by physicians with a full scope of resuscitative capabilities. This study was also limited due to small sample size, and inability to control discrepancies in the level of training of personnel, dissimilarities between population groups, and differences in response time measures. "
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND:
Epinephrine is recommended in advanced cardiac life support guidelines for use in adult cardiac arrest, and has been used in cardiopulmonary resuscitation since 1896. Yet, despite its long time use and incorporation into guidelines, epinephrine suffers from a paucity of evidence regarding its influence on survival. This critical review was conducted to address the knowledge deficit regarding epinephrine in out-of-hospital cardiac arrest and its effect on return of spontaneous circulation, survival to hospital discharge, and neurological performance.
The EMBASE and MEDLINE (through the Pubmed interface) databases, and the Cochrane library were searched with the key words “epinephrine”, “cardiac arrest” and variations of these terms. Original research studies concerning epinephrine use in adult, out-of-hospital cardiac arrest were selected for further review.
The search yielded nine eligible studies based on inclusion criteria. This includes five prospective cohort studies, one retrospective cohort study, one survival analysis, one case control study, and one RCT. The evidence clearly establishes an association between epinephrine and increased return of spontaneous circulation, the data were conflicting concerning survival to hospital discharge and neurological outcome.
The results of this review exhibit the paucity of evidence regarding the use of epinephrine in out of hospital cardiac arrest. There is currently insufficient evidence to support or reject its administration during resuscitation. Larger sample, placebo controlled, double blind, randomized control trials need to be performed to definitively establish the effect of epinephrine on both survival to hospital discharge and the neurological outcomes of treated patients.
"At present, 218 emergency and critical care centers are found in the 47 Japanese prefectures. Of these centers, 86 have physician-staffed pre-hospital advanced cardiac life support (ACLS) systems . In these physician-staffed units, physicians carry out a wide variety of emergency treatments - including endotracheal intubation, the insertion of central venous catheters, and the infusion of many different medications, including catecholamines, lidocaine, anesthetic drugs, and even thrombolytics - that exceed ELST capabilities. "
[Show abstract][Hide abstract] ABSTRACT: This review will summarize some of the data published in 2010 and focus on papers published in Critical Care in regard to cardiac arrest and cardiopulmonary resuscitation. In particular, we discuss the latest research in therapeutic hypothermia after cardiac arrest, including methods of inducing hypothermia, potential protective mechanisms, spontaneous hypothermia versus therapeutic hypothermia, and several predictors of outcome. Furthermore, we will discuss the effects of bystander-initiated cardiopulmonary resuscitation (CPR) in patients with physician-assisted advanced cardiac life support, the role of hypercapnea in near-death experiences during cardiac arrest, markers of endothelial injury and endothelial repair after CPR, and the prognostic value of cell-free plasma DNA as a marker of poor outcome after cardiac arrest.
"The Japanese EMS system is one-tiered. Several regions have their own physician-staffed EMS systems [14,17]. On receipt of an emergency call to a dispatch center in such regions, the EMS personnel request mobilization of a physician-staffed ambulance from an emergency medical center if the patient is suspected of OHCA . "
[Show abstract][Hide abstract] ABSTRACT: There are inconsistent data about the effectiveness of prehospital physician-staffed advanced cardiac life support (ACLS) on the outcomes of out-of-hospital cardiac arrest (OHCA). Furthermore, the relative importance of bystander-initiated cardiopulmonary resuscitation (BCPR) and ACLS and the effectiveness of their combination have not been clearly demonstrated.
Using a prospective, nationwide, population-based registry of all OHCA patients in Japan, we enrolled 95,072 patients whose arrests were witnessed by bystanders and 23,127 patients witnessed by emergency medical service providers between 2005 and 2007. We divided the bystander-witnessed arrest patients into Group A (ACLS by emergency life-saving technicians without BCPR), Group B (ACLS by emergency life-saving technicians with BCPR), Group C (ACLS by physicians without BCPR) and Group D (ACLS by physicians with BCPR). The outcome data included 1-month survival and neurological outcomes determined by the cerebral performance category.
Among the 95,072 bystander-witnessed arrest patients, 7,722 (8.1%) were alive at 1 month, including 2,754 (2.9%) with good performance and 3,171 (3.3%) with vegetative status or worse. BCPR occurred in 42% of bystander-witnessed arrests. In comparison with Group A, the rates of good-performance survival were significantly higher in Group B (odds ratio (OR), 2.23; 95% confidence interval, 2.05 to 2.42; P < 0.01) and Group D (OR, 2.80; 95% confidence interval, 2.28 to 3.43; P < 0.01), while no significant difference was seen for Group C (OR, 1.18; 95% confidence interval, 0.86 to 1.61; P = 0.32). The occurrence of vegetative status or worse at 1 month was highest in Group C (OR, 1.92; 95% confidence interval, 1.55 to 2.37; P < 0.01).
In this registry-based study, BCPR significantly improved the survival of OHCA with good cerebral outcome. The groups with BCPR and ACLS by physicians had the best outcomes. However, receiving ACLS by physicians without preceding BCPR significantly increased the number of patients with neurologically unfavorable outcomes.
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