Stephen Bernard

University of Western Australia, Perth City, Western Australia, Australia

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Publications (77)305.92 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Preventable bystander delays following out-of-hospital cardiac arrest (OHCA) are common, and include bystanders inappropriately directing their calls for help. We retrospectively extracted Utstein-style data from the Victorian Ambulance Cardiac Arrest Registry (VACAR) for adult OHCA occurring in Victoria, Australia, between July 2002 and June 2012. Emergency medical service (EMS) witnessed events were excluded. Cases were assigned into two groups on the basis of the first bystander call for help being directed to EMS. Study outcomes were: likelihood of receiving EMS treatment; survival to hospital, and; survival to hospital discharge. A total of 44,499 adult OHCA cases attended by EMS were identified, of which first bystander calls for help were not directed to EMS in 2,842 (6.4%) cases. Calls to a relative, friend or neighbour accounted for almost 60% of the total emergency call delays. Patient characteristics and survival outcomes were consistently less favourable when calls were directed to others. First bystander call to others was independently associated with older age, male gender, arrest in private location, and arrest in a rural region. The risk-adjusted odds of treatment by EMS (OR 1.33, 95% CI 1.20-1.48), survival to hospital (OR 1.64, 95% CI 1.37-1.96) and survival to hospital discharge (OR 1.64, 95% CI 1.13-2.36) were significantly improved if bystanders called EMS first. The frequency of inappropriate bystander calls following OHCA was low, but associated with a reduced likelihood of treatment by EMS and poorer survival outcomes.
    Resuscitation 09/2014; 85(1):42-48. · 4.10 Impact Factor
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    ABSTRACT: While internationally reported survival from out-of-hospital cardiac arrest (OHCA) is improving, much of the increase is being observed in patients presenting to emergency medical services (EMS) in shockable rhythms. The purpose of this study was to assess survival and 12-month functional recovery in patients presenting to EMS in asystole or pulseless electrical activity (PEA).
    Resuscitation 08/2014; · 4.10 Impact Factor
  • Karen Smith, Stephen Bernard
    Resuscitation 06/2014; · 4.10 Impact Factor
  • Z Nehme, E Andrew, S Bernard, K Smith
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    ABSTRACT: Success rates from cardiopulmonary resuscitation (CPR) are often quantified by Utstein-style outcome reports in populations who receive an attempted resuscitation. In some cases, evidence of futility is ascertained after a partial resuscitation attempt has been administered, and these cases reduce the overall effectiveness of CPR. We examine the impact of partial resuscitation attempts on the reported outcomes of out-of-hospital cardiac arrest (OHCA) in Victoria, Australia.
    Resuscitation 06/2014; · 4.10 Impact Factor
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    ABSTRACT: To develop methods for distinguishing patients with in-hospital cardiac arrest (IHCA) from patients with out-of-hospital cardiac arrest (OHCA) in routinely collected intensive care unit registry data, and to explore the utility of the methods for describing trends in adult ICU cardiac arrest (CA) admissions and outcomes.
    Critical care and resuscitation: journal of the Australasian Academy of Critical Care Medicine 06/2014; 16(2):104-11. · 1.51 Impact Factor
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    ABSTRACT: Emergency medical service (EMS) practitioners' experience and exposure to out-of-hospital cardiac arrest (OHCA) and advanced life support (ALS) procedures could be an important factor in procedural success and patient survival. We systematically reviewed the literature to examine these associations.
    Resuscitation 05/2014; · 4.10 Impact Factor
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    ABSTRACT: To examine the impact of population density on incidence and outcome of out-of-hospital cardiac arrest (OHCA). Data were extracted from the Victorian Ambulance Cardiac Arrest Registry for all adult OHCA cases of presumed cardiac aetiology attended by the emergency medical service (EMS) between 1 January 2003 and 31 December 2011. Cases were allocated into one of five population density groups according to their statistical local area: very low density (≤ 10 people/km(2)), low density (11-200 people/km(2)), medium density (201-1000 people/km(2)), high density (1001-3000 people/km(2)), and very high density (> 3000 people/km(2)). Survival to hospital and survival to hospital discharge. The EMS attended 27 705 adult presumed cardiac OHCA cases across 204 Victorian regions. In 12 007 of these (43.3%), resuscitation was attempted by the EMS. Incidence was lower and arrest characteristics were consistently less favourable for lower population density groups. Survival outcomes, including return of spontaneous circulation, survival to hospital and survival to hospital discharge, were significantly poorer in less densely populated groups (P < 0.001 for all comparisons). When compared with very low density populations, the risk-adjusted odds ratios of surviving to hospital discharge were: low density, 1.88 (95% CI, 1.15-3.07); medium density, 2.49 (95% CI, 1.55-4.02); high density, 3.47 (95% CI, 2.20-5.48) and very high density, 4.32 (95% CI, 2.67-6.99). Population density is independently associated with survival after OHCA, and significant variation in the incidence and characteristics of these events are observed across the state.
    The Medical journal of Australia 05/2014; 200(8):471-5. · 2.85 Impact Factor
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    ABSTRACT: Objective: To examine the impact of population density on incidence and outcome of out-of-hospital cardiac arrest (OHCA). Design, setting and participants: Data were extracted from the Victorian Ambulance Cardiac Arrest Registry for all adult OHCA cases of presumed cardiac aetiology attended by the emergency medical service (EMS) between 1 January 2003 and 31 December 2011. Cases were allocated into one of fi ve population density groups according to their statistical local area: very low density ( 10 people/km2), low density (11–200 people/km2), medium density (201–1000 people/km2), high density (1001–3000 people/km2), and very high density (> 3000 people/km2). Main outcome measures: Survival to hospital and survival to hospital discharge. Results: The EMS attended 27 705 adult presumed cardiac OHCA cases across 204 Victorian regions. In 12 007 of these (43.3%), resuscitation was attempted by the EMS. Incidence was lower and arrest characteristics were consistently less favourable for lower population density groups. Survival outcomes, including return of spontaneous circulation, survival to hospital and survival to hospital discharge, were signifi cantly poorer in less densely populated groups (P < 0.001 for all comparisons). When compared with very low density populations, the risk-adjusted odds ratios of surviving to hospital discharge were: low density, 1.88 (95% CI, 1.15–3.07); medium density, 2.49 (95% CI, 1.55–4.02); high density, 3.47 (95% CI, 2.20–5.48) and very high density, 4.32 (95% CI, 2.67–6.99). Conclusion: Population density is independently associated with survival after OHCA, and signifi cant variation in the incidence and characteristics of these events are observed across the state.
    The Medical journal of Australia 05/2014; 200(8):471. · 2.85 Impact Factor
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    ABSTRACT: Following findings of the Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage (CRASH-2) trial, tranexamic acid (TxA) use post trauma is becoming widespread. However, issues of generalisability, applicability and predictability beyond the context of study sites remain unresolved. Internal and external validity of the CRASH-2 trial are currently lacking and therefore incorporation of TxA into routine trauma resuscitation guidelines appears premature. The Pre-hospital Antifibrinolytics for Traumatic Coagulopathy and Haemorrhage (PATCH)-Trauma study is a National Health and Medical Research Council-funded randomised controlled trial of early administration of TxA in severely injured patients likely to have acute traumatic coagulopathy. The study population chosen has high mortality and morbidity and is potentially most likely to benefit from TxA's known mechanisms of action. This and further trials involving appropriate sample populations are required before evidence based guidelines on TxA use during trauma resuscitation can be developed.
    Emergency medicine Australasia: EMA 04/2014; 26(2):194-7. · 0.99 Impact Factor
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    ABSTRACT: Pre-hospital intubation by paramedics is widely used in comatose patients prior to transportation to hospital, but the optimal technique for intubation is uncertain. One approach is paramedic rapid sequence intubation (RSI), which may improve outcomes in adult patients with traumatic brain injury. However, many patients present to emergency medical services with coma of non-traumatic cause and the role of paramedic RSI in these patients remains uncertain. The electronic Victorian Ambulance Clinical Information System was searched for the term 'suxamethonium' between 2008 and 2011. We reviewed the patient care records and included patients with suspected non-traumatic coma who were treated and transported by road-based paramedics. Demographics, intubation conditions, vital signs (before and after drug administration) and complications were recorded. Younger patients (<60 years) were compared with older patients. There were 1152 paramedic RSI attempts of which 551 were for non-traumatic coma. The success rate for intubation was 97.5%. There was a significant drop in blood pressure in younger patients (<60 years) with the mean systolic blood pressure decreasing by 16 mm Hg (95% CI 11 to 21). In older patients, the systolic blood pressure also decreased significantly by 20 mm Hg (95% CI 17 to 24). Four patients suffered brief cardiac arrest during pre-hospital care, all of whom were successfully resuscitated and transported to hospital. Paramedic RSI in patients with non-traumatic coma has a high procedural success rate. Further studies are required to determine whether this procedure improves outcomes.
    Emergency Medicine Journal 01/2014; · 1.65 Impact Factor
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    ABSTRACT: Background The optimal blood pressure target following successful resuscitation from out-of-hospital cardiac arrest (OHCA) is uncertain. This study aimed to explore the association between level of systolic blood pressure (SBP) on arrival at hospital and survival to hospital discharge. Methods We analyzed eligible OHCAs occurring between January 2003 and December 2011 from the Victorian Ambulance Cardiac Arrest Register (VACAR). Inclusion criteria were: adults (≥18 years), presumed cardiac aetiology, not paramedic witnessed, and ROSC at hospital arrival. Multivariate logistic regression models were performed by initial rhythm (shockable/non-shockable) to examine the relationship between SBP at hospital arrival in 10 mmHg increments and survival to hospital discharge. Models were adjusted for known predictors of survival, including duration of arrest. Results Of 3620 eligible cases, 14% were hypotensive (SBP < 90 mmHg) on hospital arrival (10% shockable and 19% non-shockable). For patients in shockable rhythms, discharge survival was maximal at 120-129 mmHg (54%), and in the adjusted model (≥120 mmHg as reference) SBP decrements below 90 mmHg were associated with lower survival: 80-89 mmHg AOR = 0.49 (95%CI:0.24-0.95); <79 mmHg AOR = 0.24 (95%CI:0.10-0.61); unrecordable AOR = 0.10 (95%CI:0.04-0.30). In patients found in non-shockable rhythms, SBP was not significant associated with discharge survival (AOR = 1.01, 95%CI:0.89-1.15). Conclusions In an EMS system using intravenous adrenaline and fluids to maintain post-resuscitation SBP at 120 mmHg, hypotension on hospital arrival was relatively uncommon. However, in presumed cardiac OHCA patients with an initial shockable rhythm, SBPs below 90 mmHg was associated with significant lower odds of survival to hospital discharge. This level of hypotension may indicate patients who require more aggressive post-resuscitation blood pressure management.
    Resuscitation 01/2014; · 4.10 Impact Factor
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    ABSTRACT: Currently emergency medical services (EMS) that provide advanced cardiac life support (ACLS) at scene do not routinely transport out-of-hospital cardiac arrest (OHCA) patients without sustained return of spontaneous circulation (ROSC). This is due to logistical difficulties and historical poor outcomes. However, new technology for mechanical chest compression, has made transport to hospital safer and extracorporeal membrane oxygenation during cardiopulmonary resuscitation (ECPR) enabling further intervention, may result in ROSC. We aimed to explore the characteristics and outcomes of patients with OHCA who were transported to hospital with ongoing CPR in the absence of ROSC, who might benefit from this new technology. The Victorian Ambulance Cardiac Arrest Registry (VACAR) was searched for adult OHCA with an initial shockable rhythm between 2003 and 2012. There were 5593 OHCA meeting inclusion criteria. Analysis was performed on 3095 (55%) of patients who did not achieve sustained ROSC in the field. Of these only 589 (20%) had ongoing CPR to hospital. There was a significant decline in rates of transport over the study period. Predictors of transport with ongoing CPR included younger patients, decreased time to first shock and intermittent ROSC prior to transport. Survival to hospital discharge occurred in 52 (9%) of patients who had ongoing CPR to hospital. In an EMS that provides ACLS at scene, patients without ROSC in the field who receive CPR to hospital have poor outcomes. Developing a system which provides safe transport with ongoing CPR to a hospital that provides ECPR, should be considered.
    Resuscitation 12/2013; · 4.10 Impact Factor
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    ABSTRACT: Laboratory and clinical studies have suggested that hyperoxia early after resuscitation from cardiac arrest may increase neurological injury and worsen outcome. Previous clinical studies have been small or have not included relevant prehospital data. We aimed to determine in a larger cohort of patients whether hyperoxia in the intensive care unit in patients admitted after out-ofhospital cardiac arrest (OHCA) was associated with increased mortality rate after correction for prehospital variables. Data from the Victorian Ambulance Cardiac Arrest Registry (VACAR) of patients transported to hospital after resuscitation from OHCA and an initial cardiac rhythm of ventricular fibrillation between January 2007 and December 2011 were linked to the Australian and New Zealand Intensive Care Society Adult Patient Database (ANZICS-APD). Patients were allocated into three groups (hypoxia [PaO2<60mmHg], normoxia [PaO2,60-299mmHg] or hyperoxia [PaO2≥300mmHg]) according to their most abnormal PaO2 level in the first 24 hours of ICU stay. The relationship between PaO2 and hospital mortality was investigated using multivariate logistic regression analysis to adjust for confounding prehospital and ICU factors. There were 957 patients identified on the VACAR database who met inclusion criteria. Of these, 584 (61%) were matched to the ANZICS-APD and had hospital mortality and oxygen data available. The unadjusted hospital mortality was 51% in the hypoxia patients, 41% in the normoxia patients and 47% in the hyperoxia patients (P=0.28). After adjustment for cardiopulmonary resuscitation by a bystander, patient age and cardiac arrest duration, hyperoxia in the ICU was not associated with increased hospital mortality (OR, 1.2; 95% CI, 0.51-2.82; P=0.83). Hyperoxia within the first 24 hours was not associated with increased hospital mortality in patients admitted to ICU following out-of-hospital ventricular fibrillation cardiac arrest.
    Critical care and resuscitation: journal of the Australasian Academy of Critical Care Medicine 09/2013; 15(3):186-90. · 1.51 Impact Factor
  • Ziad Nehme, Emily Andrew, Stephen A Bernard, Karen Smith
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    ABSTRACT: Few studies have described the value of the precordial thump (PT) as first-line treatment of monitored out-of-hospital cardiac arrest (OHCA) from ventricular fibrillation and pulseless ventricular tachycardia (VF/VT). Patient data was extracted from the Victorian Ambulance Cardiac Arrest Registry (VACAR) for all OHCA witnessed by paramedics between 2003 and 2011. Adult patients who suffered a monitored VF/VT of presumed cardiac aetiology were included. Cases were excluded if the arrest occurred after arrival at hospital, or a 'do not resuscitate' directive was documented. Patients were assigned into two groups according to the use of the PT or defibrillation as first-line treatment. The study outcomes were: impact of first shock/thump on return of spontaneous circulation (ROSC), overall ROSC, and survival to hospital discharge. A total of 434 cases met the eligibility criteria, of which first-line treatment involved a PT in 103 (23.7%) and immediate defibrillation in 325 (74.8%) cases. Patient characteristics did not differ significantly between groups. Seventeen patients (16.5%) observed a PT-induced rhythm change, including five cases of ROSC and 10 rhythm deteriorations. Immediate defibrillation resulted in significantly higher levels of immediate ROSC (57.8% vs. 4.9%, p<0.0001), without excess rhythm deteriorations (12.3% vs. 9.7%, p=0.48). Of the five successful PT attempts, three required defibrillation following re-arrest. Overall ROSC and survival to hospital discharge did not differ significantly between groups. The PT used as first-line treatment of monitored VF/VT rarely results in ROSC, and is more often associated with rhythm deterioration.
    Resuscitation 08/2013; · 4.10 Impact Factor
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    ABSTRACT: Improved early pain control may affect the longer-term prevalence of persistent pain. In a previous randomised, controlled trial, we found that the administration of ketamine on hospital arrival decreased pain scores to a greater extent than morphine alone in patients with prehospital traumatic pain. In this follow-up study, we sought to determine the prevalence of persistent pain and whether there were differences in patients who received ketamine or morphine. This study was a long-term follow-up study of the prehospital, prospective, randomised, controlled, open-label study comparing ketamine with morphine in patients with trauma and a verbal pain score of >5 after 5 mg intravenous morphine. Patients were followed-up by telephone 6-12 months after enrolment, and a questionnaire including the SF-36 (V.2) health-related quality of life survey and the Verbal Numerical Rating Scale for pain was administered. A total of 97/135 (72%) patients were able to be followed-up 6-12 months after enrolment between July 2008 and July 2010. Overall, 44/97 (45%) participants reported persistent pain related to their injury, with 3/97 (3%) reporting persistent severe pain. The prevalence of persistent pain was the same between study groups (22/50 (44%) for the ketamine group vs 22/47 (46%) for the morphine group). There was no difference in the SF-36 scores between study arms. There is a high incidence of persistent pain after traumatic injury, even in patients with relatively minor severity of injury. Although decreased pain scores at hospital arrival are achieved with ketamine compared with morphine, this difference does not affect the prevalence of persistent pain or health-related quality of life 6 months after injury. Further larger studies are required to confirm this finding. Australian and New Zealand Clinical Trials Registry (ACTRN12607000441415).
    Emergency Medicine Journal 07/2013; · 1.65 Impact Factor
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  • Janet E Bray, Dion Stub, Stephen Bernard, Karen Smith
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    ABSTRACT: BACKGROUND: Recent studies have suggested gender differences in out-of-hospital cardiac arrests (OHCA) including outcomes favouring young women. We aimed to investigate these findings in an Australian OHCA population using the Victorian Ambulance Cardiac Arrest Registry (VACAR). METHODS AND RESULTS: The VACAR was searched for adult presumed cardiac OHCAs between 2003 and 2010 where Emergency Medical Services attempted resuscitation. Gender and age differences in survival to hospital arrival and to hospital discharge were examined using logistic regression adjusting for known predictors of survival. There were 10,453 OHCA meeting inclusion criteria (863 aged between 18-44 years). Women were less likely to be younger, have a witnessed arrest, receive bystander CPR, arrest in a public place, have an initial shockable rhythm or receive transport to 24-hour cardiac interventional hospital. After adjusting for differences in pre-hospital factors, women were more likely to survive to hospital arrival than men (aOR 3.47, 95%CI: 2.19-5.50), but no gender differences were seen in survival to hospital discharge either overall or specifically in women aged between 18 and 44 years. Both younger men and younger women were more likely to survive to hospital discharge compared to older men and women. CONCLUSION: Women were more likely to survive to hospital arrival despite less favourable baseline variables. However, this initial improvement in survival did not translate to better survival to hospital discharge either overall, or in women of a reproductive age. Further study is required to determine gender differences in the underlying causes of OHCA and in EMS transportation practices.
    Resuscitation 12/2012; · 4.10 Impact Factor
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    ABSTRACT: AIM: We describe improved reporting of paediatric out-of-hospital cardiac arrest (OHCA) by adding coronial findings to a cardiac arrest registry. METHODS: Non-traumatic OHCA occurring in paediatric patients aged less than 16 years were identified using the Victorian Ambulance Cardiac Arrest Registry and available coronial findings reviewed. RESULTS: Between the years 2001 and 2009, emergency medical services (EMS) attended 26 974 non-traumatic OHCA of which 390 (1.4%) occurred in children less than 16 years of age. We successfully linked 301 patients with the coronial registry; excluding patients discharged alive from hospital (n=22) and patients with terminal illness (n=16), this represents 86% of OHCA attended by the ambulance. Agreement between the paramedic cause of OHCA and the coronial cause of death was 66.5% (κ 0.16) for presumed cardiac, 74.4% (κ 0.43) for sudden infant death syndrome (SIDS), 81.1% (κ 0.17) for respiratory, 92.7% (κ 0.18) for neurological and 98.3% (κ 0.27) for drug overdose precipitants to OHCA. Undiagnosed congenital heart disease was a rare cause of OHCA (n=3, 1%). Intentional injury was found on autopsy in 13 cases; six cases were clinically thought to be SIDS and two cases presumed cardiac. Co-sleeping was found in 35 cases (39%) of SIDS. CONCLUSIONS: This study highlights the limitations associated with ascribing the cause of OHCA on the basis of clinical details. Improved reporting is possible by linkage with coronial data. Such robust data inform EMS service providers but also the wider healthcare system where preventive, diagnostic and treatment strategies can be maximised.
    Emergency Medicine Journal 10/2012; · 1.65 Impact Factor
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    ABSTRACT: The mortality rate post admission to hospital after successful resuscitation from out-of-hospital cardiac arrest is high, with significant variation between regions and individual institutions. Whilst pre-hospital factors such as age, bystander cardiopulmonary resuscitation and total cardiac arrest time are known to influence outcome, several aspects of post-resuscitative care including therapeutic hypothermia, coronary intervention and goal directed therapy may also influence patient survival. Regional systems of care have improved provider experience and patient outcomes for those with ST-elevation myocardial infarction and life-threatening traumatic injury. In particular, hospital factors such as hospital size and interventional cardiac care capabilities have been found to influence patient mortality. This paper reviews the evidence supporting the possible development and implementation of Australian cardiac arrest centres.
    Internal Medicine Journal 07/2012; · 1.82 Impact Factor
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    ABSTRACT: BACKGROUND: Evaluating the quality of life of young adult survivors of out-of-hospital cardiac arrest (OHCA) is important as they are likely to have a longer life expectancy than older patients. The aim of this study was to assess their functional and quality of life outcomes. METHODOLOGY: The Victorian Ambulance Cardiac Arrest Registry records were used to identify survivors of OHCA that occurred between 2003 and 2008 in the 18-39 year-old age group. Survivors were administered a telephone questionnaire using Short Form (SF-12), EQ-5D and Glasgow Outcome Scale-Extended. Cerebral Performance Category (CPC) ascertained at hospital discharge from the medical record was recorded for the uncontactable survivors. RESULTS: Of the 106 young adult survivors, five died in the intervening years and 45 were not contactable or refused. CPC scores were obtained for 37 (74%) of those who did not take part in telephone follow-up, and 7 (19%) of these had a CPC ≥3 indicating severe cerebral disability. The median follow-up time was 5 years (range 2.7- 8.6 years) for the 56 (53%) patients included. Of these, 84% were living at home independently, 68% had returned to work, and only 11% reported marked or severe disability. The majority of patients had no problems with mobility (75%), personal care (75%), usual activities (66%) or pain/discomfort (71%). However, 61% of respondents reported either moderate (48%) or severe (13%) anxiety. CONCLUSIONS: The majority of survivors have good functional and quality of life outcomes. Telephone follow-up is feasible in the young adult survivors of cardiac arrest; loss to follow-up is common.
    Emergency Medicine Journal 07/2012; · 1.65 Impact Factor

Publication Stats

4k Citations
305.92 Total Impact Points

Institutions

  • 2014
    • University of Western Australia
      Perth City, Western Australia, Australia
    • Victoria University Melbourne
      Melbourne, Victoria, Australia
  • 2008–2014
    • Alfred Hospital
      • • Department of Department of Epidemiology and Preventive Medicine (DEPM)
      • • Intensive Care Unit
      Melbourne, Victoria, Australia
  • 2003–2014
    • Ambulance Victoria
      Melbourne, Victoria, Australia
    • Monash University (Australia)
      • Department of Epidemiology and Preventive Medicine
      Melbourne, Victoria, Australia
  • 2012
    • Baker IDI Heart and Diabetes Institute
      Melbourne, Victoria, Australia