Automatic External Defibrillation and Its Effects on Neurologic Outcome in Cardiac Arrest Patients in an Urban, Two-Tiered EMS System

AbstractObjective:To describe the use of the Automatic External Defibrillation (AED) device in an urban, two-tiered Emergency Medical Service (EMS) response setting with regard to its potential effects on cardiac arrest patient survival and neurologic outcome.Methods:A retrospective and descriptive design was utilized to study all cardiac arrest patients that had resuscitations attempted in the prehospital environment over a 30-month period. The study took place in a two-tiered EMS system serving an urban population of 368,383 persons. The first tier of EMS response is provided by the City Fire Department, which is equipped with a standard AED device. All first-tier personnel are trained to the level of Emergency Medical Technician-Basic. The second tier of EMS response is provided by personnel from one of two ambulance services. All second-tier personnel are trained to the level of Emergency Medical Technician-Paramedic.Results:271 cardiac arrest patients were identified for inclusion. One-hundred nine of these patients (40.2%) had an initial rhythm of either ventricular fibrillation or pulseless ventricular tachycardia and were shocked using the AED upon the arrival of first-tier personnel. Forty-two patients (38.5%) in this group had a return of spontaneous circulation in the field and 22 (20.2%) survived to hospital discharge. Of the survivors, 17 (77.3%) had moderate to good neurologic function at discharge base on the Glasgow-Pittsburgh Cerebral Performance Categories. Faster response times by the first-tier personnel appeared to correlate with better neurologic outcomes.Conclusion:First responder-based AED usage on patients in ventricular fibrillation or pulseless ventricular tachycardia can be applied successfully in an urban setting utilizing a two-tiered EMS response. In this study, a 20.2% survival to hospital discharge rate was obtained. Seventy-seven percent of these survivors had a moderate to good neurologic outcome based on the Glasgow-Pittsburgh Cerebral Performance Categories.

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P021: Outcomes of out of hospital cardiac arrest in London, Ontario

CJEM ◽

10.1017/cem.2018.219 ◽

2018 ◽

Vol 20 (S1) ◽

pp. S64-S64

Author(s):

M. D. Clemente ◽

K. Woolfrey ◽

K. Van Aarsen ◽

M. Columbus

Keyword(s):

Cardiac Arrest ◽

Ventricular Tachycardia ◽

Ventricular Fibrillation ◽

Mortality Rate ◽

Hospital Discharge ◽

Outcome Data ◽

Neurologic Outcome ◽

Exclusion Criteria ◽

Hospital Cardiac Arrest ◽

Very High

Introduction: Out of hospital cardiac arrest (OHCA) continues to carry a very high mortality rate, with approximately 10% surviving to hospital discharge. We sought to determine if outcomes from out of hospital cardiac arrest (OHCA) at our centre were consistent with recently published North American outcomes data from the Resuscitation Outcomes Consortium (ROC). Methods: We performed a retrospective analysis (Sept 2011 June 2015) of the Resuscitation Outcomes Consortium (ROC) database, which contains pre-hospital, in-hospital and outcomes data on adult, EMS-treated, non-traumatic OHCA. Patients under 18 years, with missing age data or with obvious non-cardiac causes of arrest were excluded. Results: During the study period, there were a total of 997 OHCA; 86 met exclusion criteria. Of the 911 remaining patients, 557 (61.1%) were transported to a local ED. 92 (35.1%) were receiving ongoing CPR at the time of their presentation to the ED. Of those transported to the ED, 262 (47.0%) achieved sustained ROSC, defined as survival to ED discharge. A total of 95 patients survived to hospital discharge (36.3% of patients who achieved sustained ROSC, 17.1% of those who were transported to the ED, and 10.4% of the all OHCA). Of those who survived to hospital discharge who had neurologic outcome data, 90.5% had a modified Rankin score of 2. Initial presenting rhythm with EMS was ventricular fibrillation or pulseless ventricular tachycardia in 233 patients. Of these, 212 (91.0%) were transported to the ED, 134 (57.5%) achieved sustained ROSC, and 71 (30.5%) survived to hospital discharge. 54/60 (90.0%) of those with a documented neurologic exam had a favourable neurologic outcome. Initial presenting rhythm with EMS was PEA or asystole in 636 patients. Of these, 320 (50.3%) were transported to the ED, 115 (18.1%) achieved sustained ROSC, and 17 (2.7%) survived to hospital discharge. 9/10 (90%) of those with a documented neurologic exam had a favourable neurologic outcome. 358 of the arrests were witnessed. Of these, 274 (76.5%) were transported to the ED, 150 (41.9%) achieved sustained ROSC, and 51 (15.9%) survived to hospital discharge. 47/53 (88.7%) of those with a documented neurologic exam had a favourable neurologic outcome. Conclusion: Outcomes from out of hospital cardiac arrest in London, Ontario are comparable to other sites across North America.

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Abstract 260: Regional Routing for Extracorporeal Membrane Oxygenation to Increase Survival From Refractory Ventricular Fibrillation/Ventricular Tachycardia Out-of-Hospital Cardiac Arrest

Circulation ◽

10.1161/circ.142.suppl_4.260 ◽

2020 ◽

Vol 142 (Suppl_4) ◽

Author(s):

Nichole E Bosson ◽

Amy H Kaji ◽

James T Niemann ◽

Shira Schlesinger ◽

David Shavelle ◽

...

Keyword(s):

Cardiac Arrest ◽

Ventricular Tachycardia ◽

Ventricular Fibrillation ◽

Extracorporeal Membrane Oxygenation ◽

Neurologic Outcome ◽

Transport Time ◽

Regional System ◽

Good Neurologic Outcome ◽

Hospital Cardiac Arrest ◽

Actual Survival

Introduction: Extracorporeal membrane oxygenation (ECMO) is increasingly used to support patients with refractory ventricular fibrillation/ventricular tachycardia (rVF/VT) out-of-hospital cardiac arrest (OHCA). Los Angeles County (LAC) operates a regional system of care for 10.2 million persons, routing patients with OHCA to the closest cardiac receiving center. The purpose of this study was to determine 1) the number of patients eligible and 2) the potential for increased neurologically intact survival routing patients with rVF/VT OHCA to ECMO-capable cardiac centers. Methods: This was a retrospective study utilizing LAC quality improvement databases. Patients 18-75 years treated by EMS from 2011-2017 for rVF/VT OHCA, defined as persistent VF/VT after 3 defibrillations, were included in the analysis. Actual survival with good neurologic outcome, defined as cerebral performance category (CPC) 1 or 2, was abstracted from the LAC OHCA Registry. Theoretical patient outcome with routing directly to an ECMO-capable center was determined by applying outcomes as described by the Minnesota Resuscitation Consortium (MRC) for rVF/VT transported for ECMO. Assumptions included the availability of ECMO within a 30-minute transport time, and similar proportions of patients meeting criteria for transport/cannulation and surviving with CPC 1-2 as the MRC cohort, 78% and 40% respectively. For the remaining patients, we assumed no change in outcome. We compared the actual to the theoretical outcome with regional ECMO to determine the annual increase in survival with good neurologic outcome. Results: During the 7-year study period, there were 1862 patients with rVT/VT OHCA with outcomes available for 1454 (78%) patients. Median age was 59 years (IQR 51-66); 76% were male. Actual survival with CPC 1-2 was 13% (187 patients). Theoretical survival with CPC 1-2 in a regional ECMO-capable system was 34% (495 patients); OR 3.5 (95%CI 2.9-4.2), p<0.0001 with ECMO routing versus without. Conclusion: Assuming ECMO availability within a 30-minute transport time throughout the regional system, routing patients with rVF/VT to ECMO-capable centers could improve survival with CPC 1-2 nearly three-fold and result in 44 additional patients/year with meaningful survival.

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Treatment of ventricular fibrillation. Emergency medical technician defibrillation and paramedic services

JAMA ◽

10.1001/jama.251.13.1723 ◽

1984 ◽

Vol 251 (13) ◽

pp. 1723-1726 ◽

Cited By ~ 25

Author(s):

M. S. Eisenberg

Keyword(s):

Ventricular Fibrillation ◽

Emergency Medical Technician ◽

Emergency Medical ◽

Medical Technician

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Predictors of Survival from Perioperative Cardiopulmonary Arrests

Anesthesiology ◽

10.1097/aln.0b013e318289bafe ◽

2013 ◽

Vol 119 (6) ◽

pp. 1322-1339 ◽

Cited By ~ 38

Author(s):

Satya Krishna Ramachandran ◽

Jill Mhyre ◽

Sachin Kheterpal ◽

Robert E. Christensen ◽

Kristen Tallman ◽

...

Keyword(s):

Cardiac Arrest ◽

Ventricular Tachycardia ◽

Ventricular Fibrillation ◽

Operating Room ◽

Hospital Discharge ◽

Ventilatory Support ◽

Neurological Status ◽

Secondary Outcome ◽

Postanesthesia Care Unit ◽

Neurologically Intact

Abstract Background: Perioperative cardiopulmonary arrests are uncommon and little is known about rates and predictors of in-hospital survival. Methods: Using the Get With The Guidelines®-Resuscitation national in-hospital resuscitation registry, we identified all patients aged 18 yr or older who experienced an index, pulseless cardiac arrest in the operating room or within 24 h postoperatively. The primary outcome was survival to hospital discharge, and the secondary outcome was neurologically intact recovery among survivors. Multivariable logistic regression models using generalized estimating equation models were used to identify independent predictors of survival and neurologically intact survival. Results: A total of 2,524 perioperative cardiopulmonary arrests were identified from 234 hospitals. The overall rate of survival to discharge was 31.7% (799/2,524), including 41.8% (254/608) for ventricular tachycardia and ventricular fibrillation, 30.5% (296/972) for asystole, and 26.4% (249/944) for pulseless electrical activity. Ventricular fibrillation and pulseless ventricular tachycardia were independently associated with improved survival. Asystolic arrests occurring in the operating room and postanesthesia care unit were associated with improved survival when compared to other perioperative locations. Among patients with neurological status assessment at discharge, the rate of neurologically intact survival was 64.0% (473/739). Prearrest neurological status at admission, patient age, inadequate natural airway, prearrest ventilatory support, duration of event, and event location were significant predictors of neurological status at discharge. Conclusion: Among patients with a perioperative cardiac arrest, one in three survived to hospital discharge, and good neurological outcome was noted in two of three survivors.

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Delayed Time to Defibrillation after Intraoperative and Periprocedural Cardiac Arrest

Anesthesiology ◽

10.1097/aln.0b013e3181eaa74f ◽

2010 ◽

Vol 113 (4) ◽

pp. 782-793 ◽

Cited By ~ 28

Author(s):

Jill M. Mhyre ◽

Satya Krishna Ramachandran ◽

Sachin Kheterpal ◽

Michelle Morris ◽

Paul S. Chan ◽

...

Keyword(s):

Cardiac Arrest ◽

Ventricular Tachycardia ◽

Ventricular Fibrillation ◽

Operating Room ◽

Hospital Discharge ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

National Registry ◽

Lower Probability ◽

P Value

Background Delay in defibrillation (more than 2 min) is associated with worse survival in patients with a cardiac arrest because of ventricular fibrillation or pulseless ventricular tachycardia in intensive care units and inpatient wards. Methods We tested the relationship between delayed defibrillation and survival from intraoperative or periprocedural cardiac arrest, adjusting for baseline patient characteristics. The analysis was based on data from 865 patients who had intraoperative or periprocedural cardiac arrest caused by ventricular fibrillation or pulseless ventricular tachycardia in 259 hospitals participating in the National Registry of Cardiopulmonary Resuscitation. Results The median time to defibrillation was less than 1 min (interquartile range, <1 to 1 min). Delays in defibrillation occurred in 119 patients (13.8%). Characteristics associated with delayed defibrillation included pulseless ventricular tachycardia and noncardiac admitting diagnosis. The association between delayed defibrillation and survival to hospital discharge differed for periprocedural and intraoperative cardiac arrests (P value for interaction = 0.003). For patients arresting outside the operating room, delayed defibrillation was associated with a lower probability of surviving to hospital discharge (31.6% vs. 62.1%, adjusted odds ratio 0.49; 95% CI 0.27, 0.88; P = 0.018). In contrast, delayed defibrillation was not associated with survival for cardiac arrests in the operating room (46.8% vs. 39.6%, adjusted odds ratio 1.23, 95% CI 0.70, 2.19, P = 0.47). Conclusions Delays in defibrillation occurred in one of seven cardiac arrests in the intraoperative and periprocedural arenas. Although delayed defibrillation was associated with lower rates of survival after cardiac arrests in periprocedural areas, there was no association with survival for cardiac arrests in the operating room.

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DOuble SEquential External Defibrillation for Refractory Ventricular Fibrillation (DOSE VF): study protocol for a randomized controlled trial

Trials ◽

10.1186/s13063-020-04904-z ◽

2020 ◽

Vol 21 (1) ◽

Author(s):

Ian R. Drennan ◽

Paul Dorian ◽

Shelley McLeod ◽

Ruxandra Pinto ◽

Damon C. Scales ◽

...

Keyword(s):

Randomized Controlled Trial ◽

Cardiac Arrest ◽

Ventricular Tachycardia ◽

Ventricular Fibrillation ◽

Hospital Discharge ◽

Controlled Trial ◽

Research Question ◽

Cluster Randomized Trial ◽

Randomized Controlled ◽

Hospital Cardiac Arrest

Abstract Background Despite high-quality cardiopulmonary resuscitation (CPR), early defibrillation, and antiarrhythmic medications, some patients remain in refractory ventricular fibrillation (VF) during out-of-hospital cardiac arrest. These patients have worse outcomes compared to patients who respond to initial treatment. Double sequential external defibrillation (DSED) and vector change (VC) defibrillation have been proposed as viable options for patients in refractory VF. However, the evidence supporting the use of novel defibrillation strategies is inconclusive. The objective of this study is to compare two novel therapeutic defibrillation strategies (DSED and VC) against standard defibrillation for patients with treatment refractory VF or pulseless ventricular tachycardia (pVT) during out-of-hospital cardiac arrest. Research question Among adult (≥ 18 years) patients presenting in refractory VF or pulseless ventricular tachycardia (pVT) during out-of-hospital cardiac arrest, does DSED or VC defibrillation result in greater rates of survival to hospital discharge compared to standard defibrillation? Methods This will be a three-arm, cluster randomized trial with repeated crossover conducted in six regions of Ontario, Canada (Peel, Halton, Toronto, Simcoe, London, and Ottawa), over 3 years. All adult (≥ 18 years) patients presenting in refractory VF (defined as patients presenting in VF/pVT and remaining in VF/pVT after three consecutive standard defibrillation attempts during out-of-hospital cardiac arrest of presumed cardiac etiology will be treated by one of three strategies: (1) continued resuscitation using standard defibrillation, (2) resuscitation involving DSED, or (3) resuscitation involving VC (change of defibrillation pads from anterior-lateral to anterior-posterior pad position) defibrillation. The primary outcome will be survival to hospital discharge. Secondary outcomes will include return of spontaneous circulation (ROSC), VF termination after the first interventional shock, VF termination inclusive of all interventional shocks, and number of defibrillation attempts to obtain ROSC. We will also perform an a priori subgroup analysis comparing rates of survival for those who receive “early DSED,” or first DSED shock is shock 4–6, to those who receive “late DSED,” or first DSED shock is shock 7 or later. Discussion A well-designed randomized controlled trial employing a standardized approach to alternative defibrillation strategies early in the treatment of refractory VF is urgently required to determine if the treatments of DSED or VC defibrillation impact clinical outcomes. Trial registration ClinicalTrials.gov NCT04080986. Registered on 6 September 2019.

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Impacts of Emergency Medical Technician Configurations on Outcomes of Patients with Out-Of-Hospital Cardiac Arrest

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph17061930 ◽

2020 ◽

Vol 17 (6) ◽

pp. 1930

Author(s):

Pin-Hui Fang ◽

Yu-Yuan Lin ◽

Chien-Hsin Lu ◽

Ching-Chi Lee ◽

Chih-Hao Lin

Keyword(s):

Cardiac Arrest ◽

Life Support ◽

Advanced Life Support ◽

Spontaneous Circulation ◽

Emergency Medical Technician ◽

Population Database ◽

Emergency Medical ◽

The Impact ◽

Hospital Cardiac Arrest ◽

Medical Technician

Paramedics can provide advanced life support (ALS) for patients with out-of-hospital cardiac arrest (OHCA). However, the impact of emergency medical technician (EMT) configuration on their outcomes remains debated. A three-year cohort study consisted of non-traumatic OHCA adults transported by ALS teams was retrospectively conducted in Tainan City using an Utstein-style population database. The EMT-paramedic (EMT-P) ratio was defined as the EMT-P proportion out of all on-scene EMTs. Among the 1357 eligible cases, the median (interquartile range) number of on-scene EMTs and the EMT-P ratio were 2 (2–2) persons and 50% (50–100%), respectively. The multivariate analysis identified five independent predictors of sustained return of spontaneous circulation (ROSC): younger adults, witnessed cardiac arrest, prehospital ROSC, prehospital defibrillation, and comorbid diabetes mellitus. After adjustment, every 10% increase in the EMT-P ratio was on average associated with an 8% increased chance (adjusted odds ratio [aOR], 1.08; p < 0.01) of sustained ROSC and a 12% increase change (aOR, 1.12; p = 0.048) of favorable neurologic status at discharge. However, increased number of on-scene EMTs was not linked to better outcomes. For nontraumatic OHCA adults, an increase in the on-scene EMT-P ratio resulted in a higher proportion of improved patient outcomes.

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