Clark, Lani

OBJECTIVE : To evaluate the impact of cardiocerebral resuscitation (CCR), an alternative emergency medical services (EMS) protocol, on out-of-hospital cardiac arrest (OOHCA) survival in the state of Arizona. CCR, emphasizes 200 preshock chest compressions, a single defibrillator shock (when indicated) followed immediately by 200 postshock chest compressions, early intravenous epinephrine and delayed endotracheal intubation. METHODS : The Save Hearts in Arizona Registry and Education (SHARE) program collected Utstein style data from 38 different fire departments (FDs) servicing approximately 70% of Arizona’s population. 2671 consecutive OOHCAs, of which 1847 were adult and presumed cardiac etiology were enrolled between October, 2004 and December, 2006. The CCR protocol was implemented in 11/38 (29%) FDs and the remaining FDs 27/38 (72%) utilized standard ACLS. The primary end-point was survival to hospital discharge of all cardiac arrests and for the subgroup with witnessed arrest and ventricular fibrillation (VF) on EMS arrival. Outcomes were obtained from the Office of Vital Statistics as well as local hospitals and were compared using chi square testing; alpha = 0.05. RESULTS: 457/1847 (24.7%) patients were treated by CCR FDs and 1390/1847 (75.3%) were treated by ACLS FDs. Overall survival in the CCR group was significantly better than in the ACLS group (9.2% (42/457) vs. 3.5% (49/1390), p < 0.001). Similarly, survival for witnessed VF arrests was significantly better in the CCR group than the ACLS group (29.3% (29/99) vs. 11.1% (30/271), p < 0.001). Odds ratios were adjusted for age, gender, location, bystander CPR performed, % witnessed, % VF and EMS dispatch to arrival time. The odds of overall survival was 2.7 times higher in the CCR group compared to the overall ACLS group (95% CI 1.7,4.4), and 3.0 times higher in the CCR subgroup of witnessed VF (95% CI 1.6,5.6). CONCLUSION: Survival of patients with OOHCA in Arizona was significantly better in fire departments utilizing the cardiocerebral resuscitation protocol than in fire departments utilizing ACLS. Implementing the cardiocerebral resuscitation protocol on a large scale is feasible and saves lives.

Background The 3-hour window for treating stroke with intravenous tissue plasminogen activator (t-PA) requires well-organized, integrated efforts by emergency physicians and stroke neurologists. Objective To evaluate attitudes and knowledge of emergency physicians about intravenous t-PA for acute ischemic stroke, particularly in primary stroke centers (PSCs) with stroke neurology teams. Methods A 15-question pilot Internet survey administered by the Arizona College of Emergency Physicians. Results Between March and August 2005, 100 emergency physicians responded: 71 in Arizona and 29 in Missouri. Forty-eight percent practiced at PSCs; 48% thought t-PA was effective, 20% did not, and 32% were uncertain. PSC or non-PSC location of practice did not influence endorsement (odds ratio, 0.96; 95% confidence interval, 0.27–1.64). Of those opposing t-PA, 87% cited risk of hemorrhage. Conclusions Most emergency physicians did not endorse t-PA. Improved collaboration between emergency physicians and stroke neurologists is needed.

Background— The incidence and significance of gasping after cardiac arrest in humans are controversial. Methods and Results— Two approaches were used. The first was a retrospective analysis of consecutive confirmed out-of-hospital cardiac arrests from the Phoenix Fire Department Regional Dispatch Center text files to determine the presence of gasping soon after collapse. The second was a retrospective analysis of 1218 patients with out-of-hospital cardiac arrests in Arizona documented by emergency medical system (EMS) first-care reports to determine the incidence of gasping after arrest in relation to the various EMS arrival times. The primary outcome measure was survival to hospital discharge. An analysis of the Phoenix Fire Department Regional Dispatch Center records of witnessed and unwitnessed out-of-hospital cardiac arrests with attempted resuscitation found that 44 of 113 (39%) of all arrested patients had gasping. An analysis of 1218 EMS-attended, witnessed, out-of-hospital cardiac arrests demonstrated that the presence or absence of gasping correlated with EMS arrival time. Gasping was present in 39 of 119 patients (33%) who arrested after EMS arrival, in 73 of 363 (20%) when EMS arrival was <7 minutes, in 50 of 360 (14%) when EMS arrival time was 7 to 9 minutes, and in 25 of 338 (7%) when EMS arrival time was >9 minutes. Survival to hospital discharge occurred in 54 of 191 patients (28%) who gasped and in 80 of 1027 (8%) who did not (adjusted odds ratio, 3.4; 95% confidence interval, 2.2 to 5.2). Among the 481 patients who received bystander cardiopulmonary resuscitation, survival to hospital discharge occurred among 30 of 77 patients who gasped (39%) versus only 38 of 404 among those who did not gasp (9%) (adjusted odds ratio, 5.1; 95% confidence interval, 2.7 to 9.4). Conclusions— Gasping or abnormal breathing is common after cardiac arrest but decreases rapidly with time. Gasping is associated with increased survival. These results suggest that the recognition and importance of gasping should be taught to bystanders and emergency medical dispatchers so as not to dissuade them from initiating prompt resuscitation efforts when appropriate.