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Do early emergency calls before patient collapse improve survival after out-of-hospital cardiac arrests?
Abstract
Aim: Some out-of-hospital cardiac arrests (OHCAs) are witnessed after emergency calls. This study aimed to confirm the benefit of early emergency calls before patient collapse on survival after OHCAs witnessed by bystanders and/or emergency medical technicians (EMTs).
Methods: We analysed 278,310 witnessed OHCAs [EMT-witnessed cases (n = 54,172), bystander-witnessed cases (n = 224,138)] without pre-hospital physician involvement from all Japanese OHCA data prospectively collected between 2006 and 2012. The data were analysed for the correlation between neurologically favourable 1-month survival and the time interval between the emergency call and patient collapse.
Results: When emergency calls were placed earlier before patient collapse, the proportion of EMT-witnessed cases and survival rate after OHCAs witnessed by bystanders and EMTs were higher. When analysed only for bystander-witnessed cases, for earlier emergency calls placed before patient collapse, survival rate and incidences of bystander cardiopulmonary resuscitation (CPR) and dispatcher-assisted CPR decreased: 2.9%, 33.6% and 24.4%, respectively, for emergency calls placed >6 min before collapse and 5.5%, 48.8% and 48.5%, respectively, for those placed 1–2 min after collapse. Multivariable logistic regression showed that call-to-collapse interval (adjusted odds ratio; 95% confidence interval) (0.92; 0.90–0.94) and EMT response time after collapse (0.84; 0.82–0.86) were associated with survival after bystander-witnessed OHCAs with emergency calls before collapse.
Conclusion: Early emergency calls before patient collapse efficiently increase the proportion of EMT-witnessed cases and promotes survival after witnessed OHCAs. However, early emergency call before collapse may worsen the outcome when the patient's condition deteriorates to cardiac arrest before EMT arrival.
... DA-CPR instructions are commonly given to callers in Japan 21,22 when these callers and bystanders have not provided BCPR on victims of OHCA due to poor CPR training experience and/or lack of confidence of their skill and judgement. [22][23][24] Since these bystanders initiated BCPR few minutes after dialling the emergency number, this action may be classified as the call-first action. However, the quality of BCPR performed by these bystanders has been reported to be poor. ...
... Third, any parameter for CPR quality was not collected; this is essential in achieving better OHCA outcomes. 22,30 Finally, longer observation periods for outcomes are usually recommended; however, the outcomes were only measured at 1-M in this study. 31 Despite these limitations, this study provides the first clinical evidence for judging the advantages of call-first and CPRfirst actions and suggested the importance of immediate CPR after recognition of cardiac arrests. ...
To assess the benefit of immediate call or cardiopulmonary resuscitation (CPR) for survival from out-of-hospital cardiac arrests (OHCAs).
Of 952,288 OHCAs in 2005-2012, 41,734 were bystander-witnessed cases without prehospital involvement of physicians but with bystander CPR (BCPR) on bystander's own initiative. From those OHCAs, we finally extracted the following three call/BCPR groups: immediate Call+CPR (N=10,195, emergency call/BCPR initiated at 0 or 1min after witness, absolute call-BCPR time interval=0 or 1min), immediate Call-First (N=1,820, emergency call placed at 0 or 1min after witness, call-to-BCPR interval=2-4min), immediate CPR-First (N=5,446, BCPR initiated at 0 or 1min after witness, BCPR-to-call interval=2-4min). One-month neurologically favourable survivals were compared among the groups. Critical comparisons between Call-First and CPR-First groups were made considering arrest aetiology, age, and bystander-patient relationship after confirming the interactions among variables.
The overall survival rates in immediate Call+CPR, Call-First, and CPR-First groups were 11.5, 12.4, and 11.5%, respectively without significant differences (p=0.543). Subgroup analyses by multivariate logistic regression following univariate analysis disclosed that CPR-first group is more likely to survive in subgroups of noncardiac aetiology (adjusted odds ratio; 95% confidence interval, 2.01; 1.39-2.98) and of nonelderly OHCAs (1.38; 1.09-1.76).
Immediate CPR-first action followed by an emergency call without a large delay may be recommended when a bystander with sufficient skills to perform CPR witnesses OHCAs in nonelderly people and of noncardiac aetiology.
Copyright © 2015. Published by Elsevier Ireland Ltd.
... Stoga bi bol u grudima trebalo prepoznati kao simptom ishemije miokarda. Prepoznavanje bola u grudima i pozivanje hitne službe pre nego što osoba kolabira, omogućava hitnoj medicinskoj pomoći da stigne ranije, što dovodi do boljeg preživljavanja 8,9 . Rano prepoznavanje je presudno, jer omogućava brže aktiviranje službe hitne medicinske pomoći i brže započinjanje KPR-a od strane laika. ...
The European Resuscitation Council (ERC) has produced these Systems Saving Lives guidelines, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include chain of survival, measuring performance of resuscitation, social media and smartphones apps for engaging community, European Restart a Heart Day, World Restart a Heart, KIDS SAVE LIVES campaign, early warning scores, rapid response systems, and medical emergency team, cardiac arrest centres and role of dispatcher. The Systems Saving Lives chapter describes numerous and important factors that can globally improve the management of cardiac arrest patients not as a single intervention but as a system-level approach. The aim of this paper is to provide evidence-informed best practice guidance, about interventions which can be implemented by healthcare systems to improve outcomes of out-of-hospital and/or in-hospital cardiac arrest (OHCA and IHCA). The intended audience of the paper are governments, managers of health and education systems, healthcare professionals, teachers, students and laypeople.
... Age of the patient also affects the outcome. The younger the patient, the greater the chance of survival [7,8]. For any real significance for survival at a cardiac arrest, a CPR educational effort is required to teach the large masses in a population. ...
Background:
A rapid emergency care intervention can prevent the cardiac arrest from resulting in death. In order for Cardio Pulmonary Resuscitation (CPR) to have any real significance for the survival of the patient, it requires an educational effort educating the large masses of people of whom the youth is an important part. The aim of this study was to investigate the effect of a two-hour education intervention for youth regarding their self-confidence in performing Adult Basic Life Support (BLS).
Methods:
A quantitative approach where data consist of a pre- and post-rating of seven statements by 50 participants during an intervention by means of BLS theoretical and practical education.
Results:
The two-hour training resulted in a significant improvement in the participants' self-confidence in identifying a cardiac arrest (pre 51, post 90), to perform compressions (pre 65, post 91) and ventilations (pre 64, post 86) and use a defibrillator (pre 61, post 81). In addition, to have the self-confidence to be able to perform, and to actually perform, first aid to a person suffering from a traumatic event was significantly improved (pre 54, post 89).
Conclusion:
By providing youth with short education sessions in CPR, their self-confidence can be improved. This can lead to an increased will and ability to identify a cardiac arrest and to begin compressions and ventilations. This also includes having the confidence using a defibrillator. Short education sessions in first aid can also lead to increased self-confidence, resulting in young people considering themselves able to perform first aid to a person suffering from a traumatic event. This, in turn, results in young people perceiveing themselves as willing to commence an intervention during a traumatic event. In summary, when the youth believe in their own knowledge, they will dare to intervene.
... When a person becomes acutely ill and needs emergency medical help and cannot self-alert, someone nearby can alarm the EMCC, that is a caller, defined as a family member, relative, neighbour or acquaintance. Survival can increase if the caller sounds the alarm before the person collapses and/or cardiopulmonary resuscitation (CPR) starts immediately upon a suspected cardiac arrest, that is out-of-hospital cardiac arrest (OHCA), (12)(13)(14). During an emergency call, EMDs use an electronic decision for support, an 'index for emergency medical emergency room', including, for example, instructions for telephone-assisted cardiopulmonary resuscitation (T-CPR), (15). ...
Background:
In a rural environment where distances and access to ambulance resources in people's immediate area are limited, other responders like firefighters dispatched to perform a first aid before ambulance arrives in areas where a longer response time exists; an assignment called 'While Waiting for the Ambulance' (WWFA). Knowledge is limited about the experience from a caller's perspective when a person has a life-threatening condition needing emergency help and both firefighters in a WWFA assignment and ambulance staff are involved.
Aim:
The aim of the study is to describe the emergency situation involving a WWFA assignment in a rural environment from the caller's perspective.
Method:
A descriptive design using qualitative methodology with a reflective lifeworld research (RLR) approach was used for this study, including in-depth interviews with eight callers.
Results:
An emergency situation involving WWFA assignment in a rural environment mean a sense of being lone and lonely with a vulnerability in while waiting to hand over responsibility for the affected person. Ambivalence in several dimensions arises with simultaneous and conflicting emotions. A tension between powerlessness and power of action where the throw between doubt and hope are abrupt with a simultaneous pendulum between being in a chaos and in a calm.
Conclusion:
A double ambivalence emerges between, on one hand feeling alone in the situation and having full control, on the other hand, with trust handing over the responsibility, thereby losing control. Contact with the emergency medical dispatcher becomes a saving lifeline to hold onto, and access to emergency help in the immediate area of WWFA is valuable and important. Trust and confidence are experienced when callers are met with empathy, regardless of personal acquaintance with arriving responders.
... Il existe une littérature importante sur ce sujet. Ainsi les recommandations diffusées par l'ERC intègrent-elles les résultats d'études visant à une reconnaissance précoce de l'arrêt cardiaque, avant l'effondrement [17,153,154], à la mise en oeuvre d'une RCP par un témoin [155][156][157], ou encore à engager au plus tôt une défibrillation [158,159]. ...
Introduction : L'arrêt cardiaque (AC) est considéré comme un problème majeur de santé publique. Prévenir les arrêts cardiaques, les décès consécutifs et optimiser leur prise en charge sont les objectifs partagés à la fois par les professionnels de l’urgence et les décideurs des politiques de santé publique. A l’heure de la territorialisation prenant en compte les besoins des populations, très peu d’études ont été consacrées aux variations d’incidence induites par la localisation géographique des arrêts cardiaques et les caractéristiques socio-économiques des patients. L’objectif de cette thèse est d'identifier, à partir des données du registre national des arrêts cardiaques RéAC, dans les trois départements de la petite couronne d’Ile-de-France, des clusters de communes présentant une incidence élevée ou faible en matière d’arrêt cardiaque, puis de les caractériser à partir des facteurs socio-économiques qui peuvent leur être associés. Matériel et Méthodes : Nous avons étudié les données d’arrêt cardiaque des trois départements d’Ile-de-France composant la petite couronne francilienne. Nous avons ainsi travaillé sur un ensemble de 123 communes. Les données relatives aux arrêts cardiaques ont été extraites du registre français des arrêts cardiaques RéAC. Des données socioéconomiques ont été collectées pour chacune de ces communes auprès de l’Institut National de la Statistique et des Etudes Economiques (INSEE). En termes de méthodes, nous avons eu recours à une double approche sur le plan statistique, combinant des méthodes bayésiennes afin d’étudier les variations géographiques d'incidence des arrêts cardiaques et des statistiques de scan en vue d’identifier des clusters de communes selon le niveau d’incidence des arrêts cardiaques. Enfin, nous avons caractérisé et comparé ces clusters de communes selon des facteurs socioéconomiques. Résultats : Nous avons inclus 3.414 arrêts cardiaques sur une période de deux ans, entre août 2013 et août 2015. De fortes variations géographiques - significatives - ont été observées parmi 123 municipalités : 34 présentaient un risque d'incidence élevé et 37 présentaient un risque faible. Les statistiques de scan ont permis d’identifier 7 clusters significatifs sur le plan de l’incidence des arrêts cardiaques, dont 3 clusters à faible incidence (le risque relatif variait de 0,23 à 0,54) et 4 clusters à forte incidence (avec un risque relatif de 1,43 à 2). Les clusters de municipalités ayant une incidence élevée d'AC se caractérisent par un statut socioéconomique inférieur à celui des autres (clusters d'incidence d’arrêt cardiaque faible ou normale). L'analyse a montré des relations statistiquement significatives entre les facteurs de défaveur sociale et une incidence élevée. Discussion : L’analyse des taux d’incidence standardisés et lissés dans la zone de la petite couronne parisienne révèle l’existence d’une forte hétérogénéité en termes d’incidence des arrêts cardiaques. L’utilisation des statistiques de scan nous a permis d’identifier 7 clusters significatifs, dont 4 de sur-incidence et 3 de sous-incidence. Ces résultats, les premiers en France sur cette thématique, confirment ceux déjà existants dans la littérature internationale montrant une hétérogénéité spatiale de l'incidence de l'arrêt cardiaque et l’importance de certains facteurs socio-économiques. Enfin, le recours aux statistiques de scan, différente des méthodes généralement utilisées, permet de mettre en évidence l'existence de zones à haut risque d’arrêt cardiaque [...]
... O ut-of-hospital cardiac arrest (OHCA) survival remains poor 1,2 and relies mainly on the efficacy of the chain of survival. [3][4][5][6] Wide disparities still persist regarding outcome according to characteristics of neighborhoods, and sometimes within the same community. [7][8][9][10] Among many other factors, this heterogeneity in outcome may reflect differences in population characteristics, health behaviors, and also delivery and quality of care. ...
Background
In out-of-hospital cardiac arrest (OHCA), geographic disparities in outcomes may reflect baseline variations in patients’ characteristics but may also result from differences in the number of ambulances providing basic life support (BLS) and advanced life support (ALS). We aimed at assessing the association between allocated ambulance resources and outcomes in OHCA patients in a large urban community.
Methods
From May 2011 to January 2016, we analyzed a prospectively collected Utstein database for all OHCA adults. Cases were geocoded according to 19 neighborhoods and the number of BLS (firefighters performing cardiopulmonary resuscitation and applying automated external defibrillator) and ALS ambulances (medicalized team providing advanced care such as drugs and endotracheal intubation) was collected. We assessed the respective associations of Utstein parameters, socioeconomic characteristics, and ambulance resources of these neighborhoods using a mixed-effect model with successful return of spontaneous circulation as the primary end point and survival at hospital discharge as a secondary end point.
Results
During the study period, 8754 nontraumatic OHCA occurred in the Greater Paris area. Overall return of spontaneous circulation rate was 3675 of 8754 (41.9%) and survival rate at hospital discharge was 788 of 8754 (9%), ranging from 33% to 51.1% and from 4.4% to 14.5% respectively, according to neighborhoods ( P <0.001). Patient and socio-demographic characteristics significantly differed between neighborhoods ( P for trend <0.001). After adjustment, a higher density of ambulances was associated with successful return of spontaneous circulation (respectively adjusted odds-ratio [aOR], 1.31 [1.14–1.51]; P <0.001 for ALS ambulances >1.5 per neighborhood and aOR, 1.21 [1.04–1.41]; P =0.01 for BLS ambulances >4 per neighborhood). Regarding survival at discharge, only the number of ALS ambulances >1.5 per neighborhood was significant (aOR, 1.30 [1.06–1.59] P =0.01).
Conclusions
In this large urban population-based study of out-of-hospital cardiac arrests patients, we observed that allocated resources of emergency medical service are associated with outcome, suggesting that improving healthcare organization may attenuate disparities in prognosis.
... They recommended an immediate (1-2 minutes after collapse) CPR first BLS action, followed by an emergency call without a large (>4 min) delay. Takei et al. [37] went a step further and aimed to find and confirm the benefit of early emergency calls, even before the patient's collapse on survival after OHCAs. They observed that survival rate after OHCAs witnessed by bystanders and EMTs were higher when emergency calls were placed before patient's collapse and concluded that while calls before the patient's collapse efficiently increases the proportion of EMT-witnessed cases and improves survival after witnessed OHCAs, early calls prior to the collapse may possibly worsen the outcome if the patient's condition deteriorates to CA before arrival of the EMTs. ...
... Both bystanders and those who manage the emergency calls must immediately recognize cardiac arrest in order to promptly activate the survival chain (2). The key symptoms for recognizing a cardiac arrest are: the victim is unresponsive, does not breathe normally and does not show any signs of circulation (3,4). ...
Background and aim of the work:
The treatment of cardiac arrest in an extra-hospital environment improves with the increase in the number of people able to establish an early Cardio-Pulmonary Reanimation (CPR). The main aim of the study was to assess the validity of the two-step method in case of prolonged CPR.
Methods:
A randomized comparison study was conducted in the University Nursing School of a Northern Italian town, during the 2015/16 academic year, among 60 students, to teach them CPR techniques, through two different teaching methods (4-step and the 2-step of CPR training). The effectiveness of the maneuvers performed on mannequins equipped with skill-meter was verified.
Results:
Our study did not highlight any significant difference between the two methods of CPR training. The comparison between the two methods regarding their efficacy in practical teaching of CPR, highlighted by this study, proved the validity of both the 4-minute continuous method (1st method) and the 30:2 method (2nd method).
Conclusions:
The results of the study showed no differences between the 2-step and the 4-step methods, in the effectiveness of cardiac massage. The correct execution of chest compressions during a CPR is the key to increase the patient's chances of rescue. Research has shown that any interruption in the execution of chest compressions, leads to a progressive reduction of the effectiveness of cardiac massage, with negative consequences on the prognosis of the patient undergoing at CPR.
... They recommended an immediate (1-2 minutes after collapse) CPR first BLS action, followed by an emergency call without a large (>4 min) delay. Takei et al. [37] went a step further and aimed to find and confirm the benefit of early emergency calls, even before the patient's collapse on survival after OHCAs. They observed that survival rate after OHCAs witnessed by bystanders and EMTs were higher when emergency calls were placed before patient's collapse and concluded that while calls before the patient's collapse efficiently increases the proportion of EMT-witnessed cases and improves survival after witnessed OHCAs, early calls prior to the collapse may possibly worsen the outcome if the patient's condition deteriorates to CA before arrival of the EMTs. ...
Objective: To perform a meta-analysis of observational studies addressing whether Dispatcher Assisted Cardiopulmonary Resuscitation (DACPR), compared with independent Bystander Cardiopulmonary Resuscitation (BCPR), increases the rates of BCPR, and whether they alter survival outcomes in out-of-hospital cardiac arrests (OHCA). Methods: Relevant published articles from PubMed and Cochrane databases were studied. The baseline information and outcome data (BCPR rates, survival to hospital discharge, 1-month survival) were extracted from the out-of-hospital cardiac arrest subgroup. Meta-analyses were performed by using STATA 11.0 software. Results: Eight studies involving 29,989 patients were eligible. Overall meta-analysis showed that DACPR was associated with statistically improved rates of BCPR (Odds Ratio [OR], 4.136 [95% confidence interval, 3.741-4.531]), and survival to discharge/ 1-month survival (OR, 1.185 [95% confidence interval, 1.089-1.281]) when compared with no BCPR and Odds Ratio [OR], 1.124 [95% confidence interval, 0.9792-1.456] when compared to independent BCPR. Conclusion: This study found that DACPR resulted in greater survival rate as compared to independent BCPR and no BCPR in OHCAs. Considering that DACPR also resulted in significantly higher rates of BCPR, DACPR should be a standard protocol for EMS systems worldwide.
... patients with suspected cardiac arrest or any other life-threatening emergency. 8 Traditionally, telephonic activation of emergency medical services (EMS) has been performed primarily by the use of landline phones. However, widespread use of mobile phones has increased the rate of emergency calls made using mobile phones. ...
Purpose:
To investigate the impacts of emergency calls made using mobile phones on the quality of dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) and survival from out-of-hospital cardiac arrests (OHCAs) that were not witnessed by emergency medical service (EMS).
Methods:
In this prospective study, we collected data for 2530 DA-CPR-attempted medical emergency cases (517 using mobile phones and 2013 using landline phones) and 2980 non-EMS-witnessed OHCAs (600 using mobile phones and 2380 using landline phones). Time factors and quality of DA-CPR, backgrounds of callers and outcomes of OHCAs were compared between mobile and landline phone groups.
Results:
Emergency calls are much more frequently placed beside the arrest victim in mobile phone group (52.7% vs. 17.2%). The positive predictive value and acceptance rate of DA-CPR in mobile phone group (84.7% and 80.6%, respectively) were significantly higher than those in landline group (79.2% and 70.9%). The proportion of good-quality bystander CPR in mobile phone group was significantly higher than that in landline group (53.5% vs. 45.0%). When analysed for all non-EMS-witnessed OHCAs, rates of 1-month survival and 1-year neurologically favourable survival in mobile phone group (7.8% and 3.5%, respectively) were higher than those in landline phone group (4.6% and 1.9%; p<0.05). Multiple logistic regression analysis, including other backgrounds, revealed that mobile phone calls were associated with increased 1-month survival in the subgroup of OHCAs receiving bystander CPR (adjusted odds ratio, 1.84; 95% CI, 1.15-2.92).
Conclusion:
Emergency calls made using mobile phones are likely to augment the survival from OHCAs by improving DA-CPR.
... 19 Recognising the cardiac origin of chest pain, and calling the emergency services before a victim collapses, enables the emergency medical service to arrive sooner, hopefully before cardiac arrest has occurred, thus leading to better survival. [20][21][22][23] Once cardiac arrest has occurred, early recognition is critical to enable rapid activation of the EMS and prompt initiation of bystander CPR. The key observations are unresponsiveness and not breathing normally. ...
... Recognising the cardiac origin of chest pain, and calling the emergency services before a victim collapses, enables the emergency medical service to arrive sooner, hopefully before cardiac arrest has occurred, thus leading to better survival. [24][25][26] Once cardiac arrest has occurred, early recognition is critical to enable rapid activation of the EMS and prompt initiation of bystander CPR. The key observations are unresponsiveness and not breathing normally. ...
This executive summary provides the essential treatment algorithms for the resuscitation of children and adults and highlights the main guideline changes since 2010. Detailed guidance is provided in each of the ten sections, which are published as individual papers within this issue of Resuscitation. The sections of the ERC Guidelines 2015 are:
Objectives
The aim of this study was to compare the endotracheal tube (ET) and intravenous (IV) administration of epinephrine relative to concentration maximum, time to maximum concentration, mean concentration over time (MC), area under the curve, odds, and time to return of spontaneous circulation (ROSC) in a normovolemic pediatric cardiac arrest model.
Methods
Male swine weighing 24–37 kg were assigned to 4 groups: ET (n = 8), IV (n = 7), cardiopulmonary resuscitation (CPR) + defibrillation (CPR + Defib) (n = 5), and CPR only (n = 3). Swine were placed arrest for 2 minutes, and then CPR was initiated for 2 minutes. Epinephrine (0.1 mg/kg) for the ET group or 0.01 mg/kg for the IV was administered every 4 minutes or until ROSC. Defibrillation started at 3 minutes and continued every 2 minutes for 30 minutes or until ROSC for all groups except the CPR-only group. Blood samples were collected over a period of 5 minutes.
Results
The MC of plasma epinephrine for the IV group was significantly higher at the 30- and 60-second time points ( P = 0.001). The ET group had a significantly higher MC of epinephrine at the 180- and 240-second time points ( P < 0.05). The concentration maximum of plasma epinephrine was significantly lower for the ET group (195 ± 32 ng/mL) than for the IV group (428 ± 38 ng/mL) ( P = 0.01). The time to maximum concentration was significantly longer for the ET group (145 ± 26 seconds) than for the IV group (42 ± 16 seconds) ( P = 0.01). No significant difference existed in area under the curve between the 2 groups ( P = 0.62). The odds of ROSC were 7.7 times greater for the ET versus IV group. Time to ROSC was not significantly different among the IV, ET, and CPR + Defib groups ( P = 0.31).
Conclusions
Based on the results of this study, the ET route of administration should be considered a first-line intervention.
Background: Survival from out of hospital cardiac arrest (OHCA) increases when effective cardiopulmonary resuscitation (CPR) and defibrillation are performed early. Patients who suffer OHCA in front of emergency medical services (EMS) clinicians have greater likelihood of survival, but little is known about how EMS clinicians think about and experience those events. We sought to understand how EMS clinicians assessed patients who devolved to cardiac arrest in in their presence and uncover the perceived barriers and facilitators associated with recognizing and treating witnessed OHCAs.
Methods: EMS clinicians who had attended an EMS-witnessed OHCA and consented to participate were interviewed within 72 hours of the index case. Transcripts of the interviews were coded through the consolidated framework for implementation research to understand enabling and constraining factors involved and the predictability and anticipation of OHCA and subsequent management of patient care. Utstein data points, interventions, and associated times were extracted from the medical records.
Results: We interviewed 29 EMS clinicians who attended 27 EMS-witnessed OHCAs. Twenty-six (96.3%) of the EMS-witnessed OHCAs were preceded by prodromal symptoms and were classified as predictable. Of the predictable cases, clinicians anticipated 53.8% of them and attributed the prodromes of other cases to serious but not peri-arrest etiologies. Participants described various environmental, crew, and intrapersonal enabling and constraining factors associated with recognizing and treating EMS-witnessed OHCAs. Environmental elements included issues of safety and physical locations, crew elements included familiarity with their partners and working with them in the past, and intrapersonal elements included abilities to collect information and stress associated with responding to and managing the calls.
Conclusion: Recognition and treatment of EMS-witnessed OHCAs are influenced by numerous environmental, crew, and intrapersonal factors. Future training and education on OHCA should include diverse locations, situations, and crew make-up, along with non-traditional patient complaints to broaden experiences associated with cardiac arrest management.
Der Herz-Kreislauf-Stillstand ist die führende Todesursache in Europa. Trotz Fortschritten in der Therapie des Herz-Kreislauf-Stillstandes und dem daraus resultierenden Post- Reanimations-Syndroms überleben nur knapp 10% diesen Zustand. Ein Großteil davon trägt schwerste bleibende neurologische Einschränkungen davon. Die extrakorporale kardiopulmonale Reanimation stellt, insbesondere bei präklinischer Anlage, eine vielversprechende erweiterte Therapieoption zur Verbesserung des neurologisch guten Überlebens im therapierefraktären Herz-Kreislauf-Stillstand dar.
In der vorliegenden Arbeit wurde in einem realitätsnahen Schweinemodell der außerklinische therapierefraktäre Herz-Kreislauf-Stillstand mit präklinischer Anlage einer extrakorporalen Zirkulation abgebildet. Dabei wurde die extrakorporale kardiopulmonale Reanimation, so wie sie vielerorts bereits praktiziert wird, gegen einen weiterentwickelten Therapieansatz, der kontrollierten, automatisierten Ganzkörperreperfusion, genannt CARL, verglichen.
Es konnte gezeigt werden, dass die Reperfusion mit den standardmäßig gewählten Einstellungen im Rahmen der bisherigen extrakorporalen Reanimation zu schweren hypotensiven Phasen und einer massiven Hyperoxygenierung bei gleichzeitiger Hyperkapnie führt. Zudem bleiben die pathophysiologischen Wege des Post-Reanimations-Syndroms durch diese Anwendung therapeutisch unangetastet. Die extrakorporale Reanimation, wie sie aktuell umgesetzt wird, schöpft damit also einen Großteil ihres Potentials nicht aus.
Durch CARL ist es nun erstmalig möglich, bereits präklinisch die wichtigsten Reperfusionsparameter zu messen, sowie patientenindividuell, im Sinne eines guten neurologischen Gesamtüberlebens, zu modifizieren. Zudem werden durch das Einbinden therapeutischer Maßnahmen, die in den Leitlinien geforderten Ansätze zur Post- Reanimations-Behandlung in die Präklinik verlagert und somit bereits deutlich früher umgesetzt. So konnten hier durch hohe, pulsatile Blutflüsse, gepaart mit einer frühen Rhythmuskonversion und gerichteten Blutdrucktherapie, keine Hypotensionen beobachtet werden. Durch die kontrollierte Oxygenierung und Dekarboxylierung blieben zudem hyperkapnische Hyperoxygenierungen aus. Gleichzeitig wurde dem Post-Reanimations- Syndrom frühzeitig, unter anderem durch die therapeutische Hypothermie, der hochonkotisch-hyperosmolaren Reperfusionslösung oder der Calciumsenkung, entgegengewirkt.
Die Weiterentwicklung der aktuell durchgeführten extrakorporalen Reanimation, hin zu einer patientenindividuellen, kontrollierten Ganzkörperreperfusion, beispielsweise mit CARL, birgt somit das Potential die extrakorporale Reanimation und somit das Outcome nach HKS weiter zu verbessern. Erste Ergebnisse am Menschen zeigten diesbezüglich vielversprechende Ergebnisse.
The European Resuscitation Council (ERC) has produced these Systems Saving Lives guidelines, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The following topics are covered: chain of survival, measuring performance of resuscitation, social media and smartphones apps for engaging the community, European Restart a Heart Day, World Restart a Heart, KIDS SAVE LIVES campaign, lower-resource setting, European Resuscitation Academy and Global Resuscitation Alliance, early warning scores, rapid response systems, and medical emergency team, cardiac arrest centres and role of dispatchers.
The European Resuscitation Council (ERC) has produced these Systems Saving Lives guidelines, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include chain of survival, measuring performance of resuscitation, social media and smartphones apps for engaging community, European Restart a Heart Day, World Restart a Heart, KIDS SAVE LIVES campaign, lower-resource setting, European Resuscitation Academy and Global Resuscitation Alliance, early warning scores, rapid response systems, and medical emergency team, cardiac arrest centres and role of dispatcher.
Aims:
Japanese emergency medical services (EMS) personnel providing advance life support confirm the absence of a carotid pulse before initiating chest compressions (CCs) in adult out-of-hospital cardiac arrest (OHCA). This study aims to investigate the efficacy of a new protocol facilitating early CCs before definitive cardiac arrest in enhancing the outcomes of OHCA.
Methods:
The 2011 new protocol facilitated EMS to initiate CCs when the carotid pulse was weak and/or <50/min in comatose adult patients with respiratory arrest (apnoea or agonal breathing) and loss of the radial pulse. During 2008-2015, we compared the neurologically favourable 1-year survival rate of EMS-witnessed OHCA and EMS-confirmed out-of-hospital respiratory arrest (OHRA) in adults before (N = 257 and 34, respectively) and after (N = 255 and 54, respectively) the implementation of the new protocol.
Results:
After the new protocol, EMS initiated CCs >1.5 min before definitive cardiac arrest in 31% (80/255) and 33% (18/54) of EMS-witnessed OHCA and EMS-confirmed OHRA, respectively. While the new protocol was not significantly associated with survival of EMS-confirmed OHRA, it was significantly associated with survival of EMS-witnessed OHCA: 9.0% and 14.9%, before and after, P by univariate analysis <0.03; adjusted OR (95% CI) by multivariable logistic regression analysis, 2.01 (1.04-3.90). Neither early start of CCs nor the new protocol was associated with the progression to cardiac arrest in 212 cases with impending cardiac arrest.
Conclusions:
A new EMS protocol facilitating early CCs before definitive cardiac arrest was associated with higher survival of EMS-witnessed OHCA.
Treating out-of-hospital cardiac arrests (OHCAs) is extremely challenging due to their unpredictability and urgency of intervention. However, the usage of public automated external defibrillators (AEDs) generally improves survival outcomes.
With this research, we contribute to existing literature by proposing a comprehensive and efficient prescriptive optimization method that guides the deployment of AEDs that ultimately could improve survival rates.
Our methodology accounts for the uncertainty of future cardiac arrest locations and incorporates the creation of candidate locations for AED placement. The latter enables controlling the granularity of possible AED locations and affects the solution quality. The proposed heuristic optimization methods comprise an efficient and effective Greedy heuristic and a more complex hybrid algorithm that is based on a combination of the Greedy Randomized Adaptive Search Procedure and Simulated Annealing with several extensions.
We employ the proposed methodology to 43 municipalities in the Netherlands using real data from an established cardiac arrest registry. By relocating existing AEDs, we show that the average proportion of instances where an AED can be retrieved within the first critical 6 minutes can be improved from 47.2% to 68.5%. Using the more realistic decaying coverage function, the coverage of future cardiac arrests improves by 73.5%.
The European recommendations on cardiac arrest are based on the evidence gathered and reviewed by the International Resuscitation Liaison Committee (ILCOR) and were published in October 2015. These recommendations without representing a revolution, constitute an evolution centered on a primary goal to increase survival following cardiac arrest. This improvement in survival depends on four main factors: early identification of cardiac arrest, early access to rescue, early and quality CPR, and access to early defibrillation. These recommendations underline the importance of the interactions between the actors involved in the management of cardiac arrest: medical emergency dispatching personnel, the first provider who administers the CPR and the actors responsible for the deployment of public access defibrillation.
Copyright © 2017 Elsevier Masson SAS. All rights reserved.
Introduction:
Telephone CPR (T-CPR) has significant variations in time from call receipt to first compression, with reported delays of up to five minutes. Ireland's National Ambulance Service (NAS) uses T-CPR based on standard AMPDS questions; we aimed to identify the time to first compression and the times needed for question blocks. Ireland has a low survival rate from out-of-hospital cardiac arrest, (6% in 2013).
Methods:
A retrospective review of all cardiac arrests in a two-year period was carried out in one NAS region. All cardiac arrests were identified from the national registry and audio tapes and Patient Care Reports reviewed, together with survival data. Times from call handover were noted and categorised in terms of the key question items.
Results:
202 cardiac arrests occurred in the period (36/10(5)/year); 30 (14.9%) patients were not in cardiac arrest at the time of the call. Records were available for 145/172 patients in cardiac arrest at the time of the call. In 63/145 (43.4%) cases, the caller was not at the patient's side. Of the remaining 82 cases, in 13/82 (15.8%) CPR was underway (two survivors), in 22/82 (26.8%) the caller would not attempt T-CPR (one survivor); in 47/82 (57.3%), T-CPR was carried out (two survivors). Median time to first compression was 05:28minutes (range 03:18 to 10:29). Repeated questioning in relation to the patient's condition caused most of the delays.
Conclusions:
Many callers are willing to attempt T-CPR but the questioning/instruction process causes significant delays. A focused, brief questioning process is required.
Current guidelines for cardiopulmonary resuscitation (CPR) emphasise that emergency medical service (EMS) dispatchers should identify sudden cardiac arrest (CA) with abnormal breathing and assist lay rescuers performing CPR. However, lay rescuers description of abnormal breathing may be inconsistent, and it is unclear how EMS dispatchers provide instruction for CPR based on the breathing status of the CA victims described by laypersons.
To investigate the incidence of abnormal breathing and the association between the EMS dispatcher-assisted CPR instruction and layperson CPR, we retrospectively analysed 283 witnessed CA cases whose information regarding breathing status of CA victims was available from population-based prospective cohort data. In 169 cases (59.7%), laypersons described that the CA victims were breathing in various ways, and that the victims were 'not breathing' in 114 cases (40.3%). Victims described as breathing in various ways were provided EMS dispatch-instruction for CPR less frequently than victims described as 'not breathing' (27.8% (47/169) vs 84.2% (96/114); p<0.001). Multivariate logistic regression showed that EMS dispatch-instruction for CPR was associated significantly with layperson CPR (adjusted OR, 11.0; 95% CI, 5.72 to 21.2).
This population-based study indicates that 60% of CA victims showed agonal respiration, which was described as breathing in various ways at the time of EMS call. Although EMS dispatch-instruction was associated significantly with an increase in layperson CPR, abnormal breathing was associated with a much lower rate of CPR instruction and, in turn, was related to a much lower rate of bystander CPR.
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.
La mort sobtada representa un problema clínic per resoldre que succeeix amb molta freqüència. En un elevat percentatge de casos, l'origen es cardíac. La mort sobtada d'origen cardíac es la conseqüència final de múltiplesmecanismes fisiopatològics possibles, que promouen un substrat arritmogènic de manera aguda o crònica. El desenvolupament d'un o múltiples factors desencadenants pot interactuar amb el substrat arritmogènic i facilitar l'arítmia final amb característiques letals. A pesar de que l'estratificació de risc de les poblacions es factible, la prevenció delsmecanismes desencadenants i promotors de malalties es la mesura més necessària i correcta. El tractament amb el cardioversor-desfibril.lador implantable (ICD) és el més segur per la gran majoria de persones en les que s'ha pogut interrompre la mort sobtada cardíaca. Només en un petit subgrup de pacients molt seleccionats, la teràpia amb fàrmacs, l'ablació transcateter, la cirurgia antitaquicàrdica o el trasplantament de cor poden ésser considerades com el tractament electiu. La decisió del millor tractament per cada pacient cal considerar-la de forma individualitzada, tenint en compte les seves característiques, el tipus d'arítmia que ha sofert el pacient i la pròpia experiència de cada hospital en un tècnica determinada. Sudden death is a frequent event whose causes may not be anticipated, but often has a cardiac origin. Sudden cardiac death is the final consequence of many pathophysiological mechanisms which have caused acute or chronic arrhythmogenic disease. Single or multifactorial triggering factors may interact with the arrhythmogenic substrate to lead to lethal arrhythmias. Stratifying populations according to risk is feasible, but the immediate priority is prevention of triggering and disease-promoting factors. ICD therapy is the best treatment for most survivors of sudden cardiac death. Drug therapy, catheter ablation, antitachycardia surgery or heart transplant are only first-choice treatments for very few patients. Choosing the best therapy is an individual decision based on the patient's clinical picture, the type of arrhythmia seen and hospital experience in the various techniques
In Australia, cardiac arrest kills 142 out of every 100,000 people each year; with only 3-4% of out-of-hospital patients with cardiac arrest in Melbourne surviving to hospital discharge. Prompt initiation of cardiopulmonary resuscitation (CPR), defibrillation, and advanced cardiac care greatly improves the chances of survival from cardiac arrest. A critical step in survival is identifying by the emergency ambulance dispatcher potential of the probability that the person is in cardiac arrest. The Melbourne Metropolitan Ambulance Service (MAS) uses the computerized call-taking system, Medical Priority Dispatch System (MPDS), to triage incoming, emergency, requests for ambulance responses. The MPDS is used in many emergency medical systems around the world, however, there is little published evidence of the system's efficacy.
This study attempts to undertake a sensitivity/specificity analysis to determine the ability of MPDS to detect cardiac arrest.
Emergency ambulance dispatch records of all cases identified as suspected cardiac arrest by MPDS were matched with ambulance, patient-care records and records from the Victorian Ambulance Cardiac Arrest Registry to determine the number of correctly identified cardiac arrests. Additionally, cases that had cardiac arrests, but were not identified correctly at the point of call-taking, were examined. All data were collected retrospectively for a three-month period (01 January through 31 March 2003).
The sensitivity of MPDS in detecting cardiac arrest was 76.7% (95% confidence interval (CI): 73.6%-79.8%) and specificity was 99.2% (95% CI: 99.1-99.3%). These results indicate that cardiac arrests are correctly identified in 76.7% of cases.
Although the system correctly identified 76.7% of cardiac arrest cases, the number of false negatives suggests that there is room for improvement in recognition by MPDS to maximize chances for survival in out-of-hospital cardiac arrest. This study provides an objective and comprehensive measurement of the accuracy of MPDS cardiac-arrest detection in Melbourne, as well as providing a baseline for comparison with subsequent changes to the MPDS.
Utstein-style guidelines contribute to improved public health internationally by providing a structured framework with which to compare emergency medical services systems. Advances in resuscitation science, new insights into important predictors of outcome from out-of-hospital cardiac arrest, and lessons learned from methodological research prompted this review and update of the 2004 Utstein guidelines. Representatives of the International Liaison Committee on Resuscitation developed an updated Utstein reporting framework iteratively by meeting face to face, by teleconference, and by Web survey during 2012 through 2014. Herein are recommendations for reporting out-of-hospital cardiac arrest. Data elements were grouped by system factors, dispatch/recognition, patient variables, resuscitation/postresuscitation processes, and outcomes. Elements were classified as core or supplemental using a modified Delphi process primarily based on respondents’ assessment of the evidence-based importance of capturing those elements, tempered by the challenges to collect them. New or modified elements reflected consensus on the need to account for emergency medical services system factors, increasing availability of automated external defibrillators, data collection processes, epidemiology trends, increasing use of dispatcher-assisted cardiopulmonary resuscitation, emerging field treatments, postresuscitation care, prognostication tools, and trends in organ recovery. A standard reporting template is recommended to promote standardized reporting. This template facilitates reporting of the bystander-witnessed, shockable rhythm as a measure of emergency medical services system efficacy and all emergency medical services system-treated arrests as a measure of system effectiveness. Several additional important subgroups are identified that enable an estimate of the specific contribution of rhythm and bystander actions that are key determinants of outcome.
Outcome after cardiac arrest and cardiopulmonary resuscitation is dependent on critical interventions, particularly early defibrillation, effective chest compressions, and advanced life support. Utstein-style definitions and reporting templates have been used extensively in published studies of cardiac arrest, which has led to greater understanding of the elements of resuscitation practice and progress toward international consensus on science and resuscitation guidelines. Despite the development of Utstein templates to standardize research reports of cardiac arrest, international registries have yet to be developed. In April 2002, a task force of the International Liaison Committee on Resuscitation (ILCOR) met in Melbourne, Australia, to review worldwide experience with the Utstein definitions and reporting templates. The task force revised the core reporting template and definitions by consensus. Care was taken to build on previous definitions, changing data elements and operational definitions only on the basis of published data and experience derived from those registries that have used Utstein-style reporting. Attention was focused on decreasing the complexity of the existing templates and addressing logistical difficulties in collecting specific core and supplementary (ie, essential and desirable) data elements recommended by previous Utstein consensus conferences. Inconsistencies in terminology between in-hospital and out-of-hospital Utstein templates were also addressed. The task force produced a reporting tool for essential data that can be used for both quality improvement (registries) and research reports and that should be applicable to both adults and children. The revised and simplified template includes practical and succinct operational definitions. It is anticipated that the revised template will enable better and more accurate completion of all reports of cardiac arrest and resuscitation attempts. Problems with data definition, collection, linkage, confidentiality, management, and registry implementation are acknowledged and potential solutions offered. Uniform collection and tracking of registry data should enable better continuous quality improvement within every hospital, emergency medical services system, and community.
Dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) attempts to improve the management of out-of-hospital cardiac arrest (OHCA) by laypersons who are unable to recognize cardiac arrest and are unfamiliar with CPR. Therefore, we investigated the sensitivity and specificity of our new DA-CPR protocol for achieving implementation of bystander CPR in OHCA victims not already receiving bystander CPR.
Since 2007, we have applied a new DA-CPR protocol that uses supplementary keywords. Fire departments prospectively collected baseline data regarding DA-CPR from January 2009 to December 2011. DA-CPR was attempted in 2747 patients; of these, 417 (15.2%) did not experience cardiac arrest. The sensitivity and specificity of the 2007 protocol vs. estimated values of the previous standard protocol were 72.9% vs. 50.3% and 99.6% vs. 99.8%, respectively. We identified keywords that may be useful for detecting OHCA. Multiple logistic regression analysis revealed that the occurrence of cardiac arrest after an emergency call (odds ratio = 16.85) and placing an emergency call away from the scene of the arrest (11.04) were potentially associated with failure to provide DA-CPR. Furthermore, at-home cardiac arrest (1.61) and family members as bystanders (1.55) were associated with bystander non-compliance with DA-CPR. No complications were reported in the 417 patients who received DA-CPR but did not have cardiac arrest.
Our 2007 protocol is safe, highly specific, and may be more sensitive than the standard protocol. Understanding the factors associated with failure of bystanders to provide DA-CPR and implementing public education will be necessary to increase the benefit of DA-CPR.
Aim of the study:
The appropriate time point of evaluation of functional outcome in cardiac arrest survivors remains a matter of debate. In this cohort study we posed the hypothesis that there are no significant changes in Cerebral Performance Categories (CPC) between one month and six months after out-of hospital cardiac arrest. If changes were present we aimed to identify reasons for these changes.
Methods:
Based on a cardiac arrest registry, a potential change in CPC and mortality between one month and six months after cardiac arrest was analysed. Variables that were associated with these changes were identified.
Results:
Thirty percent of 681 patients showed a significant change in functional outcome and mortality between one month and six months after out-of hospital cardiac arrest, 12% improved in CPC, 1% deteriorated, 17% died. The only factor that was associated with an improvement in CPC in the multivariate analysis was time to restoration of spontaneous circulation (ROSC) (RRR 1.04, 95% CI 1.01-1.06, per minute). We could not find any significant factors associated with a deterioration of CPC. Factors that were associated with mortality were age (RRR 1.03, 95% CI 1.01-1.06) and ventricular fibrillation as initial cardiac rhythm (RRR 0.34, 95% CI 0.16-0.71).
Conclusions:
There is a relevant change of functional outcome even one month after out-of hospital cardiac arrest. Especially when studies compare patient groups with unequal arrest times, and an unequal distribution of initial cardiac rhythms a follow-up period longer than one month should be considered for the final outcome evaluation after cardiac arrest.
Study objective:
The Utstein guidelines recommend that emergency medical services (EMS)-witnessed cardiac arrests be considered separately from other out-of-hospital cardiac arrest cases. The objective of this study was to assess EMS-witnessed cardiac arrest and to determine predictors of survival in this group.
Methods:
This prospective cohort included all adults with an EMS-witnessed cardiac arrest in the 21 communities of the Ontario Prehospital Advanced Life Support (OPALS) study. Systems provided a basic life support with defibrillation (BLS-D) level of care. Case and survival definitions followed the Utstein style. Descriptive and univariate methods (χ(2) and t test) were used to characterize EMS-witnessed cardiac arrest. Multivariate logistic regression was undertaken to assess predictors of survival to hospital discharge.
Results:
From January 1, 1991, to December 31, 1996, there were 9,072 cardiac arrest cases in the study communities. Of these, 610 (6.7%) were EMS-witnessed. The majority had preexisting cardiac or respiratory disease (81.5%) and experienced prodromal symptoms before EMS personnel arrived (91.4%). An initial rhythm of pulseless electrical activity was present in 50.1% of the patients, ventricular fibrillation/ventricular tachycardia in 34.2%, and asystole in 15.7%. Survival to discharge was 12.6%. Multivariate analysis identified the following as independent predictors of survival (odds ratio with 95% confidence intervals [CIs]): nitroglycerin use before EMS arrival: 2.3 (95% CI 1.2 to 4.5), prodromal symptoms of chest pain: 2.5 (95% CI 1.4 to 4.5) or dyspnea: 0.5 (95% CI 0.3 to 1.0), and unconsciousness on EMS arrival: 0.5 (95% CI 0.2 to 0.9). Patients with chest pain were more likely than dyspneic patients to experience ventricular fibrillation/ventricular tachycardia (62% versus 17%, P <.0001), and were 5 times more likely to survive (30.6% versus 6.3%, P <.0001).
Conclusion:
EMS-witnessed cases are clearly an important subset of out-of-hospital cardiac arrest and are characterized by 2 distinct symptom groups: chest pain and dyspnea. These symptoms are important predictors of survival and may also help determine underlying mechanisms before patient collapse. A later phase of the OPALS study will prospectively evaluate the impact of out-of-hospital advanced life support on the survival of victims of EMS-witnessed cardiac arrest. [De Maio VJ, Stiell IG, Wells GA, Spaite DW, for the OPALS Study Group. Cardiac arrest witnessed by emergency medical services personnel: descriptive epidemiology, prodromal symptoms, and predictors of survival. Ann Emerg Med. February 2000;35:138-146.].
Objective:
Little is known about which symptoms are manifested before out-of-hospital cardiac arrest (OHCA). The objective of this study is to describe the prodromal symptoms of OHCA focusing on the onset of the symptom in relation of etiology of cardiac arrests, and to analyze the association between those symptoms and their outcomes after OHCA.
Methods:
This prospective, population-based cohort study enrolled all persons aged 18 years or older who had experienced OHCA of presumed cardiac and non-cardiac origin that were witnessed by bystanders or emergency medical system (EMS) personnel in Osaka from 2003 through 2004.
Results:
There were 1042 were presumed to be of cardiac origin and 424 of non-cardiac. Patients with non-cardiac origin were more likely to have prodromal symptoms than those with cardiac etiology (70.0% vs. 61.8%, p=0.003). Over 40% of OHCA regardless of etiology had displayed symptoms at least several minutes before their arrest (40.2% [259/644] in those of cardiac origin and 45.5% [135/297] in those of non-cardiac origin). As to cardiac origin, the most frequent prodromal symptom was dyspnea (27.6%), followed by chest pain (20.7%) and syncope (12.7%). For non-cardiac origin, the most frequent symptom was also dyspnea (40.7%), but chest pain was rarely presented (3.4%). Although, prodromal symptoms themselves were not associated with better neurological outcomes (adjusted odds ratio [AOR], 2.03; 95% confidence interval [CI], 1.00-4.13), earlier contact to a patient yielded better neurological outcomes (AOR per every one-minute increase, 0.90; 95% CI, 0.82-0.99).
Conclusions:
Many of OHCA regardless of etiology have prodromal symptoms before arrest. Prodromal symptoms induced early activation of the EMS system, and may thus improve outcomes after OHCA.
The voluntary Swedish Cardiac Arrest Registry has collected and analyzed 14,065 standardised reports on cardiac arrests up until May 1995. The reports have been collected from approximately half of Sweden's ambulance districts, which cover 60% of the population. Resuscitation was attempted in 10,966 cases. The median age was 70 years. In 70.0% the arrest was witnessed, and in 43.3% the first recorded rhythm was VT/VF. Bystander-CPR was initiated in 32.3% of the cases. Most cardiac arrests took place at home (65.8%) and 67.1% were judged to be of cardiac origin. In 1692 cases (15.4%), the patient was admitted alive in hospital and 544 patients (5.0%) were alive after 1 month. Survival to 1 month in the subgroup which presented with VT/VF was 9.5%. We found no significant difference between survival in large cities and smaller communities. The survivors were analysed in relation to time to defibrillation and we found a strong correlation between a short time and increased survival.
To identify variation in patient, event, and scene characteristics of out-of-hospital cardiac arrest (OOHCA) patients assessed by emergency medical services (EMS), and to investigate variation in transport practices in relation to documented prehospital return of spontaneous circulation (ROSC) within eight regional clinical centers participating in the Resuscitation Outcomes Consortium (ROC) Epistry-Cardiac Arrest.
OOHCA patient, event, and scene characteristics were compared to identify variation in treatment and transport practices across sites. Findings were adjusted for site and standard Utstein covariates. Using logistic regression, these covariates were modeled to identify factors related to the initiation of transport without documented prehospital ROSC as well as survival in these patients.
Eight US and Canadian sites participating in the ROC Epistry-Cardiac Arrest.
Persons ≥ 20 years with OOHCA who (a) received compressions or shock by EMS providers and/or received bystander AED shock or (b) were pulseless but received no EMS compressions or shock between December 2005 and May 2007.
23,233 OOHCA cases were assessed by EMS in the defined period. Resuscitation (treatment) was initiated by EMS in 13,518 cases (58%, site range: 36-69%, p < 0.0001). Of treated cases, 59% were transported (site range: 49-88%, p < 0.0001). Transport was initiated in the absence of documented ROSC for 58% of transported cases (site range: 14-95%, p < 0.0001). Of these transported cases, 8% achieved ROSC before hospital arrival (site range: 5-21%, p < 0.0001) and 4% survived to hospital discharge (site range: 1-21%, p < 0.0001). In cases with transport from the scene initiated after documented ROSC, 28% survived to hospital discharge (site range: 18-44%, p < 0.0001).
Initiation of resuscitation and transport of OOHCA and the reporting of ROSC prior to transport markedly varies among ROC sites. This variation may help clarify reported differences in survival rates among sites and provide a target for identifying EMS practices most likely to enhance survival from OOHCA.
Cardiopulmonary resuscitation (CPR) is a series of lifesaving actions that improve the chance of survival following cardiac arrest.1 Although the optimal approach to CPR may vary, depending on the rescuer, the victim, and the available resources, the fundamental challenge remains: how to achieve early and effective CPR. Given this challenge, recognition of arrest and prompt action by the rescuer continue to be priorities for the 2010 AHA Guidelines for CPR and ECC. This chapter provides an overview of cardiac arrest epidemiology, the principles behind each link in the Chain of Survival, an overview of the core components of CPR (see Table 1), and the approaches of the 2010 AHA Guidelines for CPR and ECC to improving the quality of CPR. The goal of this chapter is to integrate resuscitation science with real-world practice in order to improve the outcomes of CPR.
View this table:
Table 1.
Summary of Key BLS Components for Adults, Children and Infants
Despite important advances in prevention, cardiac arrest remains a substantial public health problem and a leading cause of death in many parts of the world.2 Cardiac arrest occurs both in and out of the hospital. In the US and Canada, approximately 350 000 people/year (approximately half of them in-hospital) suffer a cardiac arrest and receive attempted resuscitation.3,–,7 This estimate does not include the substantial number of victims who suffer an arrest without attempted resuscitation. While attempted resuscitation is not always appropriate, there are many lives and life-years lost because appropriate resuscitation is not attempted.
The estimated incidence of EMS-treated out-of-hospital cardiac arrest in the US and Canada is about 50 to 55/100 000 persons/year and approximately 25% of these present with pulseless ventricular arrhythmias.3,8 The estimated incidence of in-hospital cardiac arrest is 3 to 6/1000 admissions4,– …
Out of hospital cardiac arrest (OHCA) is common and lethal. It has been suggested that OHCA witnessed by EMS providers is a predictor of survival because advanced help is immediately available. We examined EMS witnessed OHCA from the Resuscitation Outcomes Consortium (ROC) to determine the effect of EMS witnessed vs. bystander witnessed and unwitnessed OHCA.
Data were analyzed from a prospective, population-based cohort study in 10 U.S. and Canadian ROC sites. Individuals with non-traumatic OHCA treated 04/01/06-03/31/07 by EMS providers with defibrillation or chest compressions were included. Cases were grouped into EMS-witnessed, bystander witnessed, and unwitnessed and further stratified for bystander CPR. Multiple logistic regressions evaluated the odds ratio (OR) for survival to discharge relative to the EMS-witnessed group after adjusting for age, sex, public/private location of collapse, ROC site, and initial ECG rhythm. Of 9991 OHCA, 1022 (10.2%) of EMS-witnessed, 3369 (33.7%) bystander witnessed, and 5600 (56.1%) unwitnessed.
The most common initial rhythm in the EMS-witnessed group was PEA which was higher than in the bystander- and unwitnessed groups (p<0.001). The adjusted OR (95% CI) of survival compared to the EMS-witnessed group was 0.41, (0.36, 0.46) in bystander witnessed with bystander CPR, 0.37 (0.33, 0.43) in bystander witnessed without bystander CPR, 0.17 (0.14, 0.20) in unwitnessed with bystander CPR and 0.21 (0.18, 0.24) in unwitnessed cases without bystander CPR.
Immediate application of prehospital care for OHCA may improve survival. Efforts should be made to educate patients to access 9-1-1 for prodromal symptoms.
The content of emergency calls for suspected cardiac arrest is rarely analyzed. This study investigated the recognition of a cardiac arrest by dispatchers and its influence on survival rates.
During 8 months, voice recordings of 14,800 consecutive emergency calls were collected to audit content and cardiac arrest recognition. The presence of cardiac arrest during the call was assessed from the ambulance crew report. Included calls were placed by laypersons on site and did not involve trauma. Prevalence of cardiac arrest was 3.0%. Of the 285 cardiac arrests, 82 (29%) were not recognized during the call, and 64 of 267 suspected calls (24%) were not cardiac arrest. We analyzed a random sample (n=506) of 9230 control calls. Three-month survival was 5% when a cardiac arrest was not recognized versus 14% when it was recognized (P=0.04). If the dispatcher did not recognize the cardiac arrest, the ambulance was dispatched a mean of 0.94 minute later (P<0.001) and arrived 1.40 minutes later on scene (P=0.01) compared with recognized calls. The main reason for not recognizing the cardiac arrest was not asking if the patient was breathing (42 of 82) and not asking to describe the type of breathing (16 of 82). Normal breathing was never mentioned in true cardiac arrest calls. A logistic regression model identified spontaneous trigger words like facial color that could contribute to cardiac arrest recognition (odds ratio, 7.8 to 9.7).
Not recognizing a cardiac arrest during emergency calls decreases survival. Spontaneous words that the caller uses to describe the patient may aid in faster and better recognition of a cardiac arrest.
To discover the frequency of agonal respirations in cardiac arrest calls, the ways callers describe them, and discharge rates associated with agonal respirations.
We reviewed taped recordings of calls reporting cardiac arrests and emergency medical technician and paramedic incident reports for 1991. Arrests after arrival of emergency medical services were excluded.
King County, Washington, excluding the city of Seattle.
Four hundred forty-five persons with out-of-hospital cardiac arrests receiving emergency medical services.
Telephone CPR, emergency medical technicians-defibrillation, and advanced life support by paramedics.
Any attempts at breathing described by callers were identified, as well as whether agonal respirations could be heard by dispatcher, emergency medical technicians, or paramedics. Agonal respirations occurred in 40% of 445 out-of-hospital cardiac arrests. Callers described agonal breathing in a variety of ways. Agonal respirations were present in 46% of arrests caused by cardiac etiology compared with 32% in other etiologies (P < .01). Fifty-five percent of witnessed arrests had agonal activity compared with 16% of unwitnessed arrests (P < .001). Agonal respirations occurred in 56% of arrests with a rhythm of ventricular fibrillation compared with 34% of cases with a nonventricular fibrillation rhythm (P < .001). Twenty-seven percent of patients with agonal respirations were discharged alive compared with 9% without them (P < .001).
There is a high incidence of agonal activity associated with out-of-hospital cardiac arrest. Presence of agonal respirations is associated with increased survival. These findings have implications for public CPR training programs and emergency dispatcher telephone CPR programs.
Prodromal symptoms and cardiac history were examined in 227 patients with coronary artery disease who were successfully resuscitated after out-of-hospital cardiac arrest. Cardiac arrest was sudden--with either no symptoms or symptoms for less than 1 hour--in 71% of the patients. Nonsudden death--death occurring after more than 1 hour of symptoms--occurred in 29% of the patients. A history of cardiovascular disease was present in 85% of patients with sudden cardiac arrest and in 83% with nonsudden arrest. Cardiac arrest occurred without symptoms in 38% of the patients with sudden cardiac arrest and was the first expression of coronary artery disease in 4% of the entire study group. This study indicates that cardiac arrest usually occurs with symptoms and almost always in the setting of a history of cardiovascular disease.
To examine the independent relationship between effectiveness of bystander cardiopulmonary resuscitation (CPR) and survival following out-of-hospital cardiac arrest.
Prospective observational cohort.
New York City.
A total of 2071 consecutive out-of-hospital cardiac arrests meeting Utstein criteria.
Trained prehospital personnel assessed the quality of bystander CPR on arrival at the scene. Satisfactory execution of CPR required performance of both adequate compressions and ventilations in conformity with current American Heart Association guidelines.
Adjusted association between CPR effectiveness and survival. Survival was defined as discharge from hospital to home.
Outcome was determined on all members of the inception cohort--none were lost to follow-up. When the association between bystander CPR and survival was adjusted for effectiveness of CPR in the parent data set (N = 2071), only effective CPR was retained in the logistic model (adjusted odds ratio [OR] = 5.7; 95% confidence interval [CI], 2.7 to 12.2; P < .001). Of the subset of 662 individuals (32%) who received bystander CPR, 305 (46%) had it performed effectively. Of these, 4.6% (14/305) survived vs 1.4% (5/357) of those with ineffective CPR (OR = 3.4; 95% CI, 1.1 to 12.1; P < .02). After adjustment for witness status, initial rhythm, interval from collapse to CPR, and interval from collapse to advanced life support, effective CPR remained independently associated with improved survival (adjusted OR = 3.9; 95% CI, 1.1 to 14.0; P < .04).
The association between bystander CPR and survival in out-of-hospital cardiac arrest appears to be confounded by CPR quality. Effective CPR is independently associated with a quantitatively and statistically significant improvement in survival.
The study objective was to develop a simple, generalizable predictive model for survival after out-of-hospital cardiac arrest due to ventricular fibrillation.
Logistic regression analysis of two retrospective series (n=205 and n=1667, respectively) of out-of-hospital cardiac arrests was performed on data sets from a Southwestern city (population, 415,000; area, 406 km2) and a Northwestern county (population, 1,038,000; area, 1399 km2). Both are served by similar two-tiered emergency response systems. All arrests were witnessed and occurred before the arrival of emergency responders, and the initial cardiac rhythm observed was ventricular fibrillation. The main outcome measure was survival to hospital discharge. Patient age, initiation of CPR by bystanders, interval from collapse to CPR, interval from collapse to defibrillation, bystander CPR/collapse-to-CPR interval interaction, and collapse-to-CPR/collapse-to-defibrillation interval interaction were significantly associated with survival. There was not a significant difference between observed survival rates at the two sites after control for significant predictors. A simplified predictive model retaining only collapse to CPR and collapse to defibrillation intervals performed comparably to the more complicated explanatory model.
The effectiveness of prehospital interventions for out-of-hospital cardiac arrest may be estimated from their influence on collapse to CPR and collapse to defibrillation intervals. A model derived from combined data from two geographically distinct populations did not identify site as a predictor of survival if clinically relevant predictor variables were controlled for. This model can be generalized to other US populations and used to project the local effectiveness of interventions to improve cardiac arrest survival.
Sudden cardiac death describes the unexpected natural death from a cardiac cause within a short time period, generally ≤ 1 h from the onset of symptoms, in a person without any prior condition that would appear fatal [1, 2]. Such a rapid death is often attributed to a cardiac arrhythmia, but with the advent of monitoring capabilities from implantable cardioverter-defibrillators (ICDs), it is now well recognized that classifications based on clinical circumstances can be misleading and often impossible, because 40% of sudden deaths can be unwitnessed [3]. Only an ECG or a ventricular electrogram recorded from an implanted device at the time of death can provide definitive information about an arrhythmia. Prodromal symptoms are often nonspecific, and even those taken to indicate ischemia (chest pain), a tachyarrhythmia (palpitations), or congestive heart failure symptoms (dyspnea) can only be considered suggestive. For these reasons, total mortality, rather than classifications of cardiac and arrhythmic mortality, should be used as primary objectives for many outcome studies.
The Utstein guidelines recommend that emergency medical services (EMS)-witnessed cardiac arrests be considered separately from other out-of-hospital cardiac arrest cases. The objective of this study was to assess EMS-witnessed cardiac arrest and to determine predictors of survival in this group.
This prospective cohort included all adults with an EMS-witnessed cardiac arrest in the 21 communities of the Ontario Prehospital Advanced Life Support (OPALS) study. Systems provided a basic life support with defibrillation (BLS-D) level of care. Case and survival definitions followed the Utstein style. Descriptive and univariate methods (chi(2) and t test) were used to characterize EMS-witnessed cardiac arrest. Multivariate logistic regression was undertaken to assess predictors of survival to hospital discharge.
From January 1, 1991, to December 31, 1996, there were 9,072 cardiac arrest cases in the study communities. Of these, 610 (6.7%) were EMS-witnessed. The majority had preexisting cardiac or respiratory disease (81.5%) and experienced prodromal symptoms before EMS personnel arrived (91.4%). An initial rhythm of pulseless electrical activity was present in 50.1% of the patients, ventricular fibrillation/ventricular tachycardia in 34.2%, and asystole in 15.7%. Survival to discharge was 12.6%. Multivariate analysis identified the following as independent predictors of survival (odds ratio with 95% confidence intervals [CIs]): nitroglycerin use before EMS arrival: 2.3 (95% CI 1.2 to 4.5), prodromal symptoms of chest pain: 2.5 (95% CI 1.4 to 4.5) or dyspnea: 0.5 (95% CI 0.3 to 1.0), and unconsciousness on EMS arrival: 0.5 (95% CI 0.2 to 0.9). Patients with chest pain were more likely than dyspneic patients to experience ventricular fibrillation/ventricular tachycardia (62% versus 17%, P<.0001), and were 5 times more likely to survive (30.6% versus 6.3%, P<.0001).
EMS-witnessed cases are clearly an important subset of out-of-hospital cardiac arrest and are characterized by 2 distinct symptom groups: chest pain and dyspnea. These symptoms are important predictors of survival and may also help determine underlying mechanisms before patient collapse. A later phase of the OPALS study will prospectively evaluate the impact of out-of-hospital advanced life support on the survival of victims of EMS-witnessed cardiac arrest.
To describe possible factors modifying the effect of bystander cardiopulmonary resuscitation on survival among patients suffering an out-of-hospital cardiac arrest.
A national survey in Sweden among patients suffering out-of-hospital cardiac arrest and in whom resuscitative efforts were attempted. Sixty per cent of ambulance organizations were included.
Prospective evaluation. Survival was defined as survival 1 month after cardiac arrest.
In all, 14065 reports were included in the evaluation. Of these, resuscitation efforts were attempted in 10966 cases, of which 1089 were witnessed by ambulance crews. The report deals with the remaining 9877 patients, of whom bystander cardiopulmonary resuscitation was attempted in 36%. Survival to 1 month was 8.2% among patients who received bystander cardiopulmonary resuscitation vs 2.5% among patients who did not receive it (odds ratio 3.5, 95% confidence interval 2.9-4.3). The effect of bystander cardiopulmonary resuscitation on survival was related to: (1) the interval between collapse and the start of bystander cardiopulmonary resuscitation (effect more marked in patients who experienced a short delay); (2) the quality of bystander cardiopulmonary resuscitation (effect more marked if both chest compressions and ventilation were performed than if either of them was performed alone); (3) the category of bystander (effect more marked if bystander cardiopulmonary resuscitation was performed by a non-layperson); (4) interval between collapse and arrival of the ambulance (effect more marked if this interval was prolonged); (5) age (effect more marked in bystander cardiopulmonary resuscitation among the elderly); and (6) the location of the arrest (effect more marked if the arrest took place outside the home).
The effect of bystander cardiopulmonary resuscitation on survival after an out-of-hospital cardiac arrest can be modified by various factors. Factors that were associated with the effect of bystander cardiopulmonary resuscitation were the interval between the collapse and the start of bystander cardiopulmonary resuscitation, the quality of bystander cardiopulmonary resuscitation, whether or not the bystander was a layperson, the interval between collapse and the arrival of the ambulance, age and the place of arrest.
To determine the association between ambulance response time and survival from out of hospital cardiopulmonary arrest and to estimate the effect of reducing response times.
Cohort study.
Scottish Ambulance Service. Subjects: All out of hospital cardiopulmonary arrests due to cardiac disease attended by the Scottish Ambulance Service during May 1991 to March 1998.
Survival rate to hospital discharge and potential improvement from reducing response times.
Of 13 822 arrests not witnessed by ambulance crews but attended by them within 15 minutes, complete data were available for 10 554 (76%). Of these patients, 653 (6%) survived to hospital discharge. After other significant covariates were adjusted for, shorter response time was significantly associated with increased probability of receiving defibrillation and survival to discharge among those defibrillated. Reducing the 90th centile for response time to 8 minutes increased the predicted survival to 8%, and reducing it to 5 minutes increased survival to 10-11% (depending on the model used).
Reducing ambulance response times to 5 minutes could almost double the survival rate for cardiac arrests not witnessed by ambulance crews.
Dispatcher-assisted telephone cardiopulmonary resuscitation (CPR) instruction can increase the proportion of sudden cardiac arrest victims who receive bystander CPR and has been associated with improved survival. Most sudden cardiac arrest victims, however, do not receive bystander CPR. The study objective was to examine factors that may impede implementation of telephone CPR.
We reviewed dispatcher audio recordings and emergency medical services reports for 404 cases of sudden cardiac arrest that occurred from July 1, 2000, to June 30, 2002, in the study county to assess the phase (1, instructions not offered; 2, instructions offered but declined; or 3, instructions offered and accepted but CPR not implemented) and specific factors within each phase that potentially impede telephone CPR.
Twenty-five percent (99/404) of victims received bystander CPR without dispatch assistance, 34% (139/404) received telephone CPR, and 41% (166/404) did not receive bystander CPR. Each phase of telephone CPR process impeded the implementation of CPR: (1) instructions not offered in 48% (80/166); (2) instructions offered but declined in 31% (52/166); and (3) instructions offered and accepted but CPR not implemented in 21% (34/166). During the first phase, telephone CPR was potentially impeded most frequently because the victim was reported to have signs of life (51/80, 64%); during the second and third phases, telephone CPR was most often impeded because of bystander physical limitation (32/86, 37%). Emotional distress, disease transmission, disagreeable victim characteristics, or medicolegal concerns uncommonly impeded telephone CPR (10/86, 12%).
Factors potentially impeding telephone CPR can be identified. Although many are logistically challenging, some may be addressable and hence provide opportunities to strengthen the chain of survival.
To explore the causes of sudden and unexpected death in a young and healthy military population, to examine the various patterns of diseases associated with these tragic events, and to investigate the factors found to be associated with this grave outcome.
We retrospectively investigated 151 cases of Israeli military personnel who died unexpectedly over a 30-year period. We collected all the available medical records, autopsy results, and investigation committee reports.
A total of 151 cases of sudden and unexpected death occurred among enlisted military personnel during the period. Cardiac disorders caused 47% of deaths, followed by neurologic causes (17%) and pulmonary causes (11%). In 30 events (20%), the cause of death remained undetermined. Symptoms (eg, syncope, chest pain, palpitations, and others) occurred prior to death in 52 cases (34%). Asthma was the most common risk factor in our study population having been previously recognized in 10 cases (6.7%). Eight of the 13 subjects with asthma died following an acute asthmatic attack.
Cardiac events are the leading cause of unexpected death in young healthy people. The frequency of subjects with asthma was found to be higher than that in the general age-adjusted population.
Outcome following cardiac arrest and cardiopulmonary resuscitation is dependent on critical interventions, particularly early defibrillation, effective chest compressions, and advanced life support. Utstein-style definitions and reporting templates have been used extensively in published studies of cardiac arrest, which has led to greater understanding of the elements of resuscitation practice and progress toward international consensus on science and resuscitation guidelines. Despite the development of Utstein templates to standardize research reports of cardiac arrest, international registries have yet to be developed. In April 2002 a task force of ILCOR met in Melbourne. Australia, to review worldwide experience with the Utstein definitions and reporting templates. The task force revised the core reporting template and definitions by consensus. Care was taken to build on previous definitions, changing data elements and operational definitions only on the basis of published data and experience derived from those registries that have used Utstein-style reporting. Attention was focused on decreasing the complexity of the existing templates and addressing logistical difficulties in collecting specific core and supplementary (i.e., essential and desirable) data elements recommended by previous Utstein consensus conference. Inconsistencies in terminology between in-hospital and out-of-hospital Utstein templates were also addressed. The task force produced a reporting tool for essential data that can be used for both quality improvement (C) 2004 Published by Elsevier Ireland Ltd.
Our aim was to report the effect of the emergency call processing in the dispatching centre on survival from out-of-hospital ventricular fibrillation (VF).
This retrospective cohort study was conducted in Helsinki Emergency Medical Services. All consecutive cases with out-of-hospital bystander witnessed VF of cardiac origin between 1 January 1997 and 31 December 2002 were included. Data were collected prospectively. Call processing times, call numbers per dispatcher and telephone guided cardiopulmonary resuscitation (CPR) were studied. Discharge alive from hospital was used as primary end point.
The study population consisted of 373 cases. Cardiac arrest (CA) was recognised in 296 cases (79.4%) by the dispatcher. Survival to discharge was 37.2% (110/296) if CA was recognised and 28.6% (22/77) if it was not recognised (p=0.1550). When the dispatcher handled <4 VF calls during the study period survival to discharge was 22.1% (17/77) compared to 38.2% (50/131) and 39.4% (65/165) when the call volume was 4-9 or >9 (p=0.0227). The mean time to dispatch a first responding unit (FRU) was 77.1+/-44.3 s. Survival to discharge was 39.4% (65/165) when the FRU dispatching time was <60s and 32.2% (67/208) when dispatching took > or =60 s (p=0.1496). The mean time to CA recognition was 170.2+/-130.1 s. Spontaneous circulation was achieved more rapidly when the time was <150 s (p=0.0426), but there was no difference in survival to discharge. Telephone guided CPR instructions were given in 123 cases (35.5%). Survival to discharge was 43.1% (53/123) when CPR instructions were given and 31.7% (72/223) when they were not given (p=0.0453).
We showed that low CA call numbers per dispatcher is associated with a decreased probability of survival. Giving telephone guided CPR instructions should be promoted as they influence the outcome. Further studies are needed to determine optimal call processing times.
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