[Show abstract][Hide abstract] ABSTRACT: To describe changes in the epidemiology of out-of-hospital cardiac arrest in Sweden with the emphasis on the younger age groups.
Prospective observational study.
Patients were recruited from the Swedish Registry of Cardiopulmonary Resuscitation from 1990 to 2012. Only non-crew-witnessed cases were included.
The endpoint was 30-day survival. Cerebral function among survivors was estimated according to the cerebral performance category scores. In all, 50,879 patients in the survey had an out-of-hospital cardiac arrest, of which 1,321 (2.6%) were 21 years old or younger and 1,543 (3.0%) were 22-35 years old. On the basis of results from 2011 and 2012, we estimated that there are 4.9 cases per 100,000 person-years in the age group 0-21 years. The highest survival was found in the 13- to 21-year age group (12.6%). Among patients 21 years old or younger, the following were associated with an increased chance of survival: increasing age, male gender, witnessed out-of-hospital cardiac arrest, ventricular fibrillation, and a short emergency medical service response time. Among patients 21 years old or younger, there was an increase in survival from 6.2% in 1992-1998 to 14.0% in 2007-2012. Among 30-day survivors, 91% had a cerebral performance category score of 1 or 2 (good cerebral performance or moderate cerebral disability) at hospital discharge.
In Sweden, among patients 21 years old or younger, five out-of-hospital cardiac arrests per 100,000 person-years occur and survival in this patient group has more than doubled during the past two decades. The majority of survivors have good or relatively good cerebral function.
Pediatric Critical Care Medicine 07/2015; DOI:10.1097/PCC.0000000000000503 · 2.34 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Cardiopulmonary resuscitation (CPR) performed by bystanders is associated with increased survival rates among persons with out-of-hospital cardiac arrest. We investigated whether rates of bystander-initiated CPR could be increased with the use of a mobile-phone positioning system that could instantly locate mobile-phone users and dispatch lay volunteers who were trained in CPR to a patient nearby with out-of-hospital cardiac arrest.
We conducted a blinded, randomized, controlled trial in Stockholm from April 2012 through December 2013. A mobile-phone positioning system that was activated when ambulance, fire, and police services were dispatched was used to locate trained volunteers who were within 500 m of patients with out-of-hospital cardiac arrest; volunteers were then dispatched to the patients (the intervention group) or not dispatched to them (the control group). The primary outcome was bystander-initiated CPR before the arrival of ambulance, fire, and police services.
A total of 5989 lay volunteers who were trained in CPR were recruited initially, and overall 9828 were recruited during the study. The mobile-phone positioning system was activated in 667 out-of-hospital cardiac arrests: 46% (306 patients) in the intervention group and 54% (361 patients) in the control group. The rate of bystander-initiated CPR was 62% (188 of 305 patients) in the intervention group and 48% (172 of 360 patients) in the control group (absolute difference for intervention vs. control, 14 percentage points; 95% confidence interval, 6 to 21; P<0.001).
A mobile-phone positioning system to dispatch lay volunteers who were trained in CPR was associated with significantly increased rates of bystander-initiated CPR among persons with out-of-hospital cardiac arrest. (Funded by the Swedish Heart-Lung Foundation and Stockholm County; ClinicalTrials.gov number, NCT01789554.).
New England Journal of Medicine 06/2015; 372(24):2316-25. DOI:10.1056/NEJMoa1406038 · 55.87 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND
Three million people in Sweden are trained in cardiopulmonary resuscitation (CPR). Whether this training increases the frequency of bystander CPR or the survival rate among persons who have out-of-hospital cardiac arrests has been questioned.
We analyzed a total of 30,381 out-of-hospital cardiac arrests witnessed in Sweden from January 1, 1990, through December 31, 2011, to determine whether CPR was performed before the arrival of emergency medical services (EMS) and whether early CPR was correlated with survival.
CPR was performed before the arrival of EMS in 15,512 cases (51.1%) and was not performed before the arrival of EMS in 14,869 cases (48.9%). The 30-day survival rate was 10.5% when CPR was performed before EMS arrival versus 4.0% when CPR was not performed before EMS arrival (P<0.001). When adjustment was made for a propensity score (which included the variables of age, sex, location of cardiac arrest, cause of cardiac arrest, initial cardiac rhythm, EMS response time, time from collapse to call for EMS, and year of event), CPR before the arrival of EMS was associated with an increased 30-day survival rate (odds ratio, 2.15; 95% confidence interval, 1.88 to 2.45). When the time to defibrillation in patients who were found to be in ventricular fibrillation was included in the propensity score, the results were similar. The positive correlation between early CPR and survival rate remained stable over the course of the study period. An association was also observed between the time from collapse to the start of CPR and the 30-day survival rate.
New England Journal of Medicine 06/2015; 372(24). DOI:10.1056/NEJMoa1405796 · 55.87 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Aims:
To describe out-of-hospital cardiac arrest (OHCA) in Sweden from a long-term perspective in terms of changes in outcome and circumstances at resuscitation.
Methods and results:
All cases of OHCA (n = 59,926) reported to the Swedish Cardiac Arrest Register from 1992 to 2011 were included. The number of cases reported (n/100,000 person-years) increased from 27 (1992) to 52 (2011). Crew-witnessed cases, cardiopulmonary resuscitation prior to the arrival of the emergency medical service (EMS), and EMS response time increased (P < 0.0001). There was a decrease in the delay from collapse to calling for the EMS in all patients and from collapse to defibrillation among patients found in ventricular fibrillation (P < 0.0001). The proportion of patients found in ventricular fibrillation decreased from 35 to 25% (P < 0.0001). Thirty-day survival increased from 4.8 (1992) to 10.7% (2011) (P < 0.0001), particularly among patients found in a shockable rhythm and patients with return of spontaneous circulation (ROSC) at hospital admission. Among patients hospitalized with ROSC in 2008-2011, 41% underwent therapeutic hypothermia and 28% underwent percutaneous coronary intervention. Among 30-day survivors in 2008-2011, 94% had a cerebral performance category score of 1 or 2 at discharge from hospital and the results were even better if patients were found in a shockable rhythm.
From a long-term perspective, 30-day survival after OHCA in Sweden more than doubled. The increase in survival was most marked among patients found in a shockable rhythm and those hospitalized with ROSC. There were improvements in all four links in the chain of survival, which might explain the improved outcome.
European Heart Journal 06/2014; 36(14). DOI:10.1093/eurheartj/ehu240 · 15.20 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVES: To evaluate the feasibility and appropriateness of a prehospital system allowing ambulance nurses to transport older adults directly to geriatric care at a community-based hospital (CH) or to an emergency department (ED). DESIGN: Randomized controlled trial. SETTING: Emergency medical services in Stockholm, Sweden. PARTICIPANTS: Older adults who called the emergency number were randomized to an intervention group (n = 410) or a control group (n = 396). INTERVENTION: The dispatcher randomized the individuals. Those randomized to the intervention group were transported to several alternative destinations decided by a trained nurse performing a comprehensive assessment, using the new prehospital system. Those randomized to the control group were transported to the ED. MEASUREMENTS: Primary endpoint: number of individuals triaged directly to a CH (feasibility). Secondary endpoint: number of subsequent transfers (appropriateness) from CH to ED within 24 hours after initial admission. RESULTS: After exclusion and crossover, the control group consisted of 217 and the intervention group of 449 older adults. The nurse sent 20% of the intervention group (90/449) (95% confidence interval (CI) = 16.6-24.0) directly to the CH when using the prehospital system. Six of those individuals (6.7%) (95% CI = 3.1-13.8) were subsequently transferred from the CH to the ED. Overall, the nurse appropriately triaged 93.3% of the participants (84/90) and transferred them to the CH, avoiding an ED visit. CONCLUSION: Ambulance nurses are able to send older adults to an alternative healthcare facility with the help of a prehospital decision support system. In this geographical setting, this appears to be a promising method to optimize resources and improve emergency care of elderly adults.
Journal of the American Geriatrics Society 06/2014; 62(7). DOI:10.1111/jgs.12888 · 4.57 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To determine the impact of a dual dispatch system, using fire fighters as first responders, in out-of-hospital cardiac arrest (OHCA) on short (30 days) and long term (three years) survival, and, to investigate the potential differences regarding in-hospital factors and interventions between the patient groups, such as the use of therapeutic hypothermia and cardiac catheterization.
OHCAs from 2004 (historical controls) and 2006-2009 (intervention period) were included. During the intervention period, fire fighters equipped with automated external defibrillators (AEDs) were dispatched in suspected OHCA. Logistic regression analyses of outcome data included: the intervention with dual dispatch, sex, age, location, aetiology, witnessed status, bystander-cardiopulmonary resuscitation, first rhythm and therapeutic hypothermia. In total, 2581 OHCAs were included (historical controls n=620, intervention period n=1961). Fire fighters initiated cardiopulmonary resuscitation and connected an AED before emergency medical services' arrival in 41% of the cases. The median time from dispatch to arrival of first responder or emergency medical services shortened from 7.7 in the control period to 6.7 min in the intervention period (p<0.001). The 30-day survival improved from 3.9% to 7.6% (p=0.001), adjusted odds ratio 2.8 (confidence interval 1.6-4.9). Survival to three years increased from 2.4% to 6.5% (p<0.001), adjusted odds ratio 3.8 (confidence interval 1.9-7.6). In the logistic regression analysis including in-hospital factors we found no outcome benefit of therapeutic hypothermia.
The implementation of a dual dispatch system using fire fighters in OHCA was associated with increased 30-day and three-year survival. No major differences in the in-hospital treatment were seen between the studied patient groups.
[Show abstract][Hide abstract] ABSTRACT: The use of supplemental oxygen in the setting of suspected acute myocardial infarction (AMI) is recommended in international treatment guidelines and established in prehospital and hospital clinical routine throughout the world. However, to date there is no conclusive evidence from adequately designed and powered trials supporting this practice. Existing data are conflicting and fail to clarify the role of supplemental oxygen in AMI.
A total of 6,600 normoxemic (oxygen saturation [SpO2] ≥90%) patients with suspected AMI will be randomly assigned to either supplemental oxygen 6 L/min delivered by Oxymask (MedCore Sweden AB, Kista, Sweden) for 6 to 12 hours in the treatment group or room air in the control group. Patient inclusion and randomization will take place at first medical contact, either before hospital admission or at the emergency department. The Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies registry will be used for online randomization, allowing inclusion of a broad population of all-comers. Follow-up will be carried out in nationwide health registries and Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies. The primary objective is to evaluate whether oxygen reduces 1-year all-cause mortality. Secondary end points include 30-day mortality, major adverse cardiac events, and health economy. Prespecified subgroups include patients with confirmed AMI and certain risk groups. In a 3-month pilot study, the study concept was found to be safe and feasible.
The need to clarify the uncertainty of the role of supplemental oxygen therapy in the setting of suspected AMI is urgent. The DETO2X-AMI trial is designed and powered to address this important issue and may have a direct impact on future recommendations.
American heart journal 03/2014; 167(3):322-8. DOI:10.1016/j.ahj.2013.09.022 · 4.46 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
Prehospital identification of acute stroke increases the possibility of early treatment and good outcome. To increase identification of stroke, the Face Arm Speech Time (FAST) test was introduced in the Emergency Medical Communication Center (EMCC). This substudy aims to evaluate the implementation of the FAST test in the EMCC and the ambulance service.
The study was conducted in the region of Stockholm, Sweden during 6 months. The study population consisted of all calls to the EMCC concerning patients presenting at least one FAST symptom or a history/finding making the EMCC or ambulance personnel to suspect stroke within 6 h. Positive FAST was compared to diagnosis at discharge. Positive predictive values (PPV) for a stroke diagnosis at discharge were calculated.
In all, 900 patients with a median age of 71 years were enrolled, 667 (74%) by the EMCC and 233 (26%) by the ambulances. At discharge, 472 patients (52%) were diagnosed with stroke/transient ischemic attack (TIA), 337 identified by the EMCC (71%) and 135 (29%) by the ambulances. The PPV for a discharge diagnosis of stroke/TIA was 51% (CI 47-54%) in EMCC-enrolled and 58% (CI 52-64%) in ambulance-enrolled patients. With a positive FAST the PPV of a correct stroke/TIA diagnosis increased to 56% (CI 52-61%) and 73% (CI 66-80%) in EMCC- and ambulance-enrolled patients, respectively. Positive FAST from EMCC was also found in 44% of patients with a nonstroke diagnosis at discharge. A stroke/TIA diagnosis at discharge but negative FAST was found in 58 and 27 patients enrolled by the EMCC and ambulances, respectively.
The PPV of FAST is higher when used on the scene by ambulance than by EMCC. FAST may be a useful prehospital tool to identify stroke/TIA but has limitations as the test can be negative in true strokes, can be positive in nonstrokes, and FAST symptoms may be present but not identified in the emergency call. For the prehospital care situation better identification tools are needed.
[Show abstract][Hide abstract] ABSTRACT: To describe recent changes in medication preceding Out-of-Hospital Cardiac Arrest (OHCA) where resuscitation was attempted.
OHCA victims were identified by the Swedish Cardiac Arrest Register and linked by means of their unique 10-digit personal identification numbers to the Prescribed Drug Register. We identified new claimed prescriptions during a six month period prior to the OHCA compared with those claimed 12-18 months before. The 7-digit ATC codes of individual drugs were used. The study period was November 2007 to January 2011 RESULTS:: OHCA victims with drugs were older than those who did not claim any drugs in any period (70±16years vs. 54±22 years p<0.001), were more often women (34% vs. 20%, p<0.001) and had more often a presumed cardiac etiology (67% vs. 54% (p<0.001), were less likely to have VT/VF as the first recorded rhythm (26% vs. 33%, p<0.001) or to survive one month (9% vs. 17%, p<0.0001). New prescriptions were claimed by 5122 (71%) of 7243 OHCA victims. The most frequently claimed new drugs were paracetamol (acetaminophen) 10.3%, furosemide 7.8% and omeprazole 7.6%. Of drugs known or supposed to cause QT prolongation, ciprofloxacin was the most frequent (3.4%) altogether; 16% had a new claimed prescription of a drug included in the ¨qtdrugs.org¨ lists.
A majority of OHCA victims had new drugs prescribed within six months prior to the event, but most often intended for diseases other than cardiac. No claims can be made as to the causality.
[Show abstract][Hide abstract] ABSTRACT: Although ozone (O3) and other pollutants have been associated with cardiovascular morbidity and mortality, the effects of O3 on out-of-hospital cardiac arrest (OHCA) have rarely been addressed and existing studies have presented inconsistent findings. The objective of this study was to determine the effects of short-term exposure to air pollution including O3 on the occurrence of OHCA, and assess effect modification by season, age, and gender.
A total of 5973 Emergency Medical Service-assessed OHCA cases in Stockholm County 2000-10 were obtained from the Swedish cardiac arrest register. A time-stratified case-crossover design was used to analyse exposure to air pollution and the risk of OHCA. Exposure to O3, PM2.5, PM10, NO2, and NOx was defined as the mean urban background level during 0-2, 0-24, and 0-72 h before the event and control time points. We adjusted for temperature and relative humidity. Ozone in urban background was associated with an increased risk of OHCA for all time windows. The respective odds ratio (confidence interval) for a 10 µg/m(3) increase was 1.02 (1.01-1.05) for a 2-h window, 1.04 (1.01-1.07) for 24-h, and 1.05 (1.01-1.09) for 3 day. The association with 2-h O3 was stronger for events that occurred outdoors: 1.13 (1.06-1.21). We observed no effects for other pollutants and no effect modification by age, gender, or season.
Short-term exposure to moderate levels of O3 is associated with an increased risk of OHCA.
European Heart Journal 12/2013; 35(13). DOI:10.1093/eurheartj/eht489 · 15.20 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Registration of data from a major incident or disaster serves several purposes such as to record data for evaluation of response as well as for research. Data needed can often be retrieved after an incident while other must be recorded during the incident. There is a need for a consensus on what is essential to record from a disaster response. The aim of this study was to identify key indicators essential for initial disaster medical response registration. By this is meant nationally accepted processes involved, from the time of the emergency call to the emergency medical communication centre until medical care is provided at the emergency department.
A three round Delphi study was conducted. Thirty experts with a broad knowledge in disaster and emergency response and medical management were invited. In this study we estimated 30 experts to be approximately one third of the number in Sweden eligible for recruitment. Process, structure and outcome indicators for the initial disaster medical response were identified. These were based on previous research and expressed as statements and were grouped into eight categories, and presented to the panel of experts. The experts were instructed to score each statement, using a five point Likert scale, and were also invited to include additional statements. Statements reaching a predefined consensus level of 80% were considered as essential to register.
In total 97 statements were generated, 77 statements reached consensus. The 77 statements covered parts of all relevant aspects involved in the initial disaster medical response. The 20 indicators that did not reach consensus mostly concerned patient related times in hospital, types of support systems and security for health care staff.
The Delphi technique can be used for reaching consensus of data, comprising process, structure and outcome indicators, identified as essential for recording from major incidents and disasters.
Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 09/2013; 21(1):68. DOI:10.1186/1757-7241-21-68 · 2.03 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
Little is known about the long-term survival effects of type-specific bystander cardiopulmonary resuscitation (CPR) in the community. We hypothesized that dispatcher instruction consisting of chest compression alone would be associated with better overall long-term prognosis in comparison with chest compression plus rescue breathing.
Methods and results:
The investigation was a retrospective cohort study that combined 2 randomized trials comparing the short-term survival effects of dispatcher CPR instruction consisting either of chest compression alone or chest compression plus rescue breathing. Long-term vital status was ascertained by using the respective National and State death records through July 31, 2011. We performed Kaplan-Meier method and Cox regression to evaluate survival according to the type of CPR instruction. Of the 2496 subjects included in the current investigation, 1243 (50%) were randomly assigned to chest compression alone and 1253 (50%) were randomly assigned to chest compression plus rescue breathing. Baseline characteristics were similar between the 2 CPR groups. During the 1153.2 person-years of follow-up, there were 2260 deaths and 236 long-term survivors. Randomization to chest compression alone in comparison with chest compression plus rescue breathing was associated with a lower risk of death after adjustment for potential confounders (adjusted hazard ratio, 0.91; 95% confidence interval, 0.83-0.99; P=0.02).
The findings provide strong support for long-term mortality benefit of dispatcher CPR instruction strategy consisting of chest compression alone rather than chest compression plus rescue breathing among adult patients with cardiac arrest requiring dispatcher assistance.