Chikani, Vatsal

Background: Bystander cardiopulmonary resuscitation (BCPR) significantly improves survival from out-of-hospital cardiac arrest (OHCA). Telecommunicator CPR (TCPR) has been shown to increase BCPR rates, yet TCPR performance varies widely. We assess whether a bundled TCPR protocol, training, and continuous quality improvement (CQI) intervention improves TCPR performance. Methods: The intervention was implemented at a regional 9-1-1 dispatch center and had three main components: (1) the installation of the AHA-recommended 2-question TCPR protocol, (2) training to enhance telecommunicator OHCA recognition and (3) CQI with system and case-level feedback. Training included a two-hour lecture, 30 minutes of video training, and one hour of simulation training. Audio recordings of suspected OHCAs from pre (P1, 10/5/10 - 11/6/11) and post-intervention (P2, 11/7/11 - 11/4/13) periods were collected by searching center archives for calls originally processed as cardiac arrests. Recordings were analyzed according to six key TCPR metrics. Times to telecommunicator recognition of cardiac arrest, start of TCPR instructions, and initiation of chest compressions were measured using a standardized timestamp format. Results: Rates of OHCA recognition (80% to 95%, p<0.0001), TCPR instructions started (32% to 72%, p<0.0001), and bystander chest compressions initiated (18% to 70%, p<0.001) all increased significantly. Reductions in the time from call receipt to the start of TCPR instructions (176s to 133s, p<0.0001) and to the start of compressions (265s to 162s, p<0.0001) were also observed. Conclusion: This bundled protocol, training and CQI intervention was associated with a significant increase in TCPR rates and a reduction in the time to first chest compression.

Introduction: Coronary angiography (CA) is recommended after out-of-hospital cardiac arrest (OHCA) when ST-elevation is present but the ideal timing and benefit of CA when ST-elevation is not present are unknown. Methods: Prospective observational study of adult (age >17) OHCA of presumed cardiac etiology from 1/01/2010-12/31/2014 who were admitted to one of 40 recognized cardiac receiving centers within a state resuscitation center network. DNR patients, those who did not achieve ROSC, and/or those who died in the ED were excluded since the likelihood of percutaneous coronary intervention (PCI) impacting outcome in these patients is low. An in-hospital database was linked with a statewide OHCA database. Results: Among 6,615 cases, 1,247 remained for analysis after exclusion [DNR (1254); failed to achieve ROSC/died in ED (4,020); missing prehospital variable (92); and missing outcome (2)]. Median age was 63 and 70% were male. There were 62% witnessed arrests, 54% received bystander CPR and the initial rhythm was VF/VT in 55%. Sixty-four percent survived to hospital discharge, 82% of which had a CPC score of 1 or 2. Of the 326 STEMI cases, 298 (91%) underwent CA with resultant PCI in 206 (63%). Of the 849 non-STEMI cases, 361 (43%) underwent CA with resultant PCI in 107 (13%). Overall survival was: 54% in cases without CA; 73% in cases with CA but without PCI; and 73% in those with PCI. Survival in non-STEMI cases was: 55% in cases without CA; 82% in cases with CA but without PCI; and 80% in those with PCI. In non-STEMI cases, the adjusted odds of survival for CA without PCI vs no CA was 2.70 (95% CI: 1.81, 4.02) and for PCI versus no CA it was 2.01 (95% CI: 1.16, 3.48). Conclusion: In this statewide analysis over 90% of OHCA cases with STEMI underwent CA. In cases that were not STEMI, CA was strongly and independently associated with survival regardless of whether PCI was performed. Since there is no reason to believe that CA without PCI confers a survival benefit, these findings suggest a component of selection bias in those without STEMI who undergo CA.

Background: Previous observational studies have demonstrated that outcomes after OHCA can be significantly improved with therapies such as mild therapeutic hypothermia and percutaneous coronary intervention (PCI). However, the optimal candidate and timing for PCI in OHCA remains unknown. This study aimed to assess the impact of emergent PCI on survival and neurological outcome after OHCA. Methods: This is a prospective observational study from a statewide OHCA database in Arizona. Patients included were greater than 18 years old who received CPR and were admitted to one of 34 recognized cardiac receiving centers. Patients who did not achieve ROSC, died within 2 hours of hospital arrival, and DNAR patients were excluded since the likelihood of PCI impacting outcome in these patients is questionable. An in-hospital post-arrest database, including PCI (Y/N), was linked with an Utstein-style OHCA database. Univariate and multivariate logistic regression were utilized to assess the association between PCI and survival to hospital discharge and neurological outcome. Results: During this study period (1-1-2011-12-31-2013), there were a total of 6,543 adult OHCA patients. After exclusions, 782 patients with suspected cardiac etiology OHCA were analyzed. The median age of patients was 64.0 years (Q1:54.0, Q3:73.0) and 70.2% were male. Among them 458 (58.6%) and 238 (30.4%) patients underwent the emergency coronary angiogram (CAG), and Primary PCI, respectively. Among PCI patients, the rate of survival to hospital discharge was 75.2%, vs. 60.4% for those without PCI (p<0.001) and good cerebral outcome (CPC 1-2) was found in 67.6%, vs. 44.3% of those without PCI (p<0.001). After adjusting for age, gender, initial rhythm, bystander CPR, and hypothermia, the Odds Ratio was 1.2 (95% CI:0.8-1.8) for survival and 2.8 (95% CI:1.5-5.1) for good neurologic outcome (CPC 1-2) among PCI patients. Conclusion: This study shows an association with emergent PCI and good neurologic outcome after OHCA. Further study is necessary to determine a potential causal relationship between PCI and outcome.

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 Emergency 9‐1‐1 callers use a wide range of terms to describe abnormal breathing in persons with out‐of‐hospital cardiac arrest ( OHCA ). These breathing descriptors can obstruct the telephone cardiopulmonary resuscitation ( CPR ) process. Methods and Results We conducted an observational study of emergency call audio recordings linked to confirmed OHCA s in a statewide Utstein‐style database. Breathing descriptors fell into 1 of 8 groups (eg, gasping, snoring). We divided the study population into groups with and without descriptors for abnormal breathing to investigate the impact of these descriptors on patient outcomes and telephone CPR process. Callers used descriptors in 459 of 2411 cases (19.0%) between October 1, 2010, and December 31, 2014. Survival outcome was better when the caller used a breathing descriptor (19.6% versus 8.8%, P <0.0001), with an odds ratio of 1.63 (95% confidence interval, 1.17–2.25). After exclusions, 379 of 459 cases were eligible for process analysis. When callers described abnormal breathing, the rates of telecommunicator OHCA recognition, CPR instruction, and telephone CPR were lower than when callers did not use a breathing descriptor (79.7% versus 93.0%, P <0.0001; 65.4% versus 72.5%, P =0.0078; and 60.2% versus 66.9%, P =0.0123, respectively). The time interval between call receipt and OHCA recognition was longer when the caller used a breathing descriptor (118.5 versus 73.5 seconds, P <0.0001). Conclusions Descriptors of abnormal breathing are associated with improved outcomes but also with delays in the identification of OHCA . Familiarizing telecommunicators with these descriptors may improve the telephone CPR process including OHCA recognition for patients with increased probability of survival.

Background— Bystander cardiopulmonary resuscitation (CPR) improves survival from out-of-hospital cardiac arrest (OHCA) but often is not performed. We hypothesized that subjects viewing very short Hands-Only CPR videos will (1) be more likely to attempt CPR in a simulated OHCA scenario and (2) demonstrate better CPR skills than untrained individuals. Methods and Results— This study is a prospective trial of 336 adults without recent CPR training randomized into 4 groups: (1) control (no training) (n=51); (2) 60-second video training (n=95); (3) 5-minute video training (n=99); and (4) 8-minute video training, including manikin practice (n=91). All subjects were tested for their ability to perform CPR during an adult OHCA scenario using a CPR-sensing manikin and Laerdal PC SkillReporting software. One half of the trained subjects were randomly assigned to testing immediately and the other half after a 2-month delay. Twelve (23.5%) controls did not even attempt CPR, which was true of only 2 subjects (0.7%; P =0.01) from any of the experimental groups. All experimental groups had significantly higher average compression rates (closer to the recommended 100/min) than the control group ( P <0.001), and all experimental groups had significantly greater average compression depth (>38 mm) than the control group ( P <0.0001). Conclusions— Laypersons exposed to very short Hands-Only CPR videos are more likely to attempt CPR and show superior CPR skills than untrained laypersons. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT01191736.

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.