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There is substantial regional variation in out-of-hospital cardiac arrest (OHCA) survival. We investigated whether regional emergency medical services (EMS) intra-arrest transport (IAT) practices are associated with patient outcomes.We performed a secondary analysis of a multi-center North American clinical trial dataset, which enrolled EMS-treated adult OHCA cases from 49 regional population-based clusters. The exposure of interest was regional-level intra-arrest transport (IAT), calculated as the proportion of cases in each cluster transported to hospital prior to return of spontaneous circulation, examined as quartiles and as a continuous variable. Multilevel mixed-effects logistic regression modeling estimated the association between regional IAT with survival to hospital discharge and favorable neurologic status (modified Rankin Scale ≤ 3) at hospital discharge.Of 26,148 subjects (median age 68 years; 36% female; 23% shockable initial rhythm) 2424 (9.3%), survived to hospital discharge and 1993 (7.6%) had favourable neurological outcomes. Across regional clusters, IAT ranged from 0.84% to 75% (quartiles6.2%, 6.2-19.6%, 19.6-30.4%, and ≥30.4%). For each quartile, 13.3%, 7.9%, 7.4%, and 4.8% survived, and 10.4%, 7.8%, 7.4%, and 4.8% had favourable neurological status. Regional IAT (per 10% change) was associated with decreased probability of survival (AOR 0.86, 95% CI 0.82-0.91) and favorable neurological outcome (AOR 0.80, 95% CI 0.76-0.85).Treatment within a region that utilizes IAT less frequently was associated with improved clinical outcomes at hospital discharge. These findings may account for some of the known regional variation in OHCA outcomes.

End-tidal carbon dioxide (ETCO2) has been suggested to have prognostic implications during out-of-hospital cardiac arrest (OHCA). Our objective was to determine if the change in ETCO2 (delta ETCO2) during resuscitation was predictive of future return of spontaneous circulation (ROSC) in patients with pulseless electrical activity (PEA) arrests.We performed a retrospective, observational study of adult (≥18 years of age) non-traumatic PEA OHCAs in two Canadian EMS systems over a two-year time frame beginning on January 1, 2018. Cases were excluded if there was a Do Not Resuscitate order (DNR), had no advanced airway, or had less than two ETCO2 recordings. We performed multivariable logistic regression to examine the association between ETCO2 measures and ROSC. Second, we examined the prognostic performance (sensitivity, specificity, NPV, PPV) for ETCO2 at specific thresholds for predicting ROSC.A total of 208 OHCA met inclusion criteria of which 67 (32%) obtained ROSC. After adjusting for pre-determined confounders, there was an association between delta ETCO2 and ROSC (odds ratio [OR] per 10 mmHg increase in ETCO2 of 1.74 (95% confidence interval [CI] 1.35 to 2.24); P value 0.001). We also found significant associations between both initial ETCO2 and final ETCO2 with ROSC.Our analysis indicates that there is a positive linear relationship between delta ETCO2 and ROSC with values of delta ETCO2 20 mmHg being highly specific for ROSC in PEA patients. As such, patients with up-trending ETCO2 values should have resuscitation continued unless there is overwhelming clinical evidence to the contrary.

This 2020 International Consensus on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care Science With Treatment Recommendations on basic life support summarizes evidence evaluations performed for 20 topics that were prioritized by the Basic Life Support Task Force of the International Liaison Committee on Resuscitation. The evidence reviews include 16 systematic reviews, 3 scoping reviews, and 1 evidence update. Per agreement within the International Liaison Committee on Resuscitation, new or revised treatment recommendations were only made after a systematic review. Systematic reviews were performed for the following topics: dispatch diagnosis of cardiac arrest, use of a firm surface for CPR, sequence for starting CPR (compressions-airway-breaths versus airway-breaths-compressions), CPR before calling for help, duration of CPR cycles, hand position during compressions, rhythm check timing, feedback for CPR quality, alternative techniques, public access automated external defibrillator programs, analysis of rhythm during chest compressions, CPR before defibrillation, removal of foreign-body airway obstruction, resuscitation care for suspected opioid-associated emergencies, drowning, and harm from CPR to victims not in cardiac arrest. The topics that resulted in the most extensive task force discussions included CPR during transport, CPR before calling for help, resuscitation care for suspected opioid-associated emergencies, feedback for CPR quality, and analysis of rhythm during chest compressions. After discussion of the scoping reviews and the evidence update, the task force prioritized several topics for new systematic reviews.

This2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendationsfor advanced life support includes updates on multiple advanced life support topics addressed with 3 different types of reviews. Topics were prioritized on the basis of both recent interest within the resuscitation community and the amount of new evidence available since any previous review. Systematic reviews addressed higher-priority topics, and included double-sequential defibrillation, intravenous versus intraosseous route for drug administration during cardiac arrest, point-of-care echocardiography for intra-arrest prognostication, cardiac arrest caused by pulmonary embolism, postresuscitation oxygenation and ventilation, prophylactic antibiotics after resuscitation, postresuscitation seizure prophylaxis and treatment, and neuroprognostication. New or updated treatment recommendations on these topics are presented. Scoping reviews were conducted for anticipatory charging and monitoring of physiological parameters during cardiopulmonary resuscitation. Topics for which systematic reviews and new Consensuses on Science With Treatment Recommendations were completed since 2015 are also summarized here. All remaining topics reviewed were addressed with evidence updates to identify any new evidence and to help determine which topics should be the highest priority for systematic reviews in the next 1 to 2 years.

Introduction Cardiac arrests associated with shockable rhythms such as ventricular fibrillation or pulseless VT (VF/pVT) are associated with improved outcomes from cardiac arrest. The more defibrillation attempts required to terminate VF/pVT, the lower the survival. Double sequential defibrillation (DSD) has been used for refractory VF/pVT cardiac arrest despite limited evidence examining this practice. We performed a systematic review to summarize the evidence related to the use of DSD during cardiac arrest. Methods This review was performed according to PRISMA and registered on PROSPERO (ID: CRD42020152575). We searched Embase, Pubmed, and the Cochrane library from inception to 28 February 2020. We included adult patients with VF/pVT in any setting. We excluded case studies, case series with less than five patients, conference abstracts, simulation studies, and protocols for clinical trials. We predefined our outcomes of interest as neurological outcome, survival to hospital discharge, survival to hospital admission, return of spontaneous circulation (ROSC), and termination of VF/pVT. Risk of bias was examined using ROBINS-I or ROB-2 and certainty of studies were reported according to GRADE methodology. Results Overall, 314 studies were identified during the initial search. One hundred and thirty studies were screened during title and abstract stage and 10 studies underwent full manuscript screening, nine included in the final analysis. Included studies were cohort studies (n = 4), case series (n = 3), case-control study (n = 1) and a prospective pilot clinical trial (n−1). All studies were considered to have serious or critical risk of bias and no meta-analysis was performed. Overall, we did not find any differences in terms of neurological outcome, survival to hospital discharge, survival to hospital admission, ROSC, or termination of VF/pVT between DSD and a standard defibrillation strategy. Conclusion The use of double sequential defibrillation was not associated with improved outcomes from out-of-hospital cardiac arrest, however the current literature has a number of limitations to interpretation. Further high-quality evidence is needed to answer this important question.

Objectives The primary objective was to determine the feasibility and safety of a cluster randomized controlled trial (RCT) with crossover comparing vector change defibrillation (VC) or double sequential external defibrillation (DSED) to standard defibrillation for patients experiencing refractory ventricular fibrillation (VF). Secondary objectives were to assess the rates of VF termination (VFT) and return of spontaneous circulation (ROSC). Methods We conducted a pilot cluster RCT with crossover in four Canadian paramedic services including all treated adult OHCA patients who presented in VF and received a minimum of three successive defibrillation attempts. Each EMS service was randomly assigned to provide standard defibrillation, VC or DSED. Agencies crossed over to an alternate defibrillation strategy after six months. Results 152 patients were enrolled. With respect to feasibility, 89.5% of cases received the defibrillation strategy they were randomly allocated to, and 93.1% of cases received a VC or DSED shock prior to the sixth defibrillation attempt. There were no safety concerns reported. In the standard group, 66.6% of cases resulted in VFT, compared to 82.0% in VC and 76.3% in the DSED group. ROSC was achieved in 25.0%, 39.3% and 40.0% of standard, VC and DSED groups, respectively. Conclusions Our findings suggest the DOSE-VF protocol is feasible and safe. Rates of VFT and ROSC were higher in the VC and DSED than standard defibrillation. The results of this pilot trial will allow us to inform a multicenter cluster RCT with crossover to determine if alternate defibrillation strategies for refractory VF may impact clinical outcomes.

Point-of-care ultrasound (POCUS) is used in cardiac arrest patients to assess for reversible causes. We aimed to conduct a diagnostic test accuracy systematic review of intra-arrest POCUS to indicate the etiology of cardiac arrest in adults in any setting.This review is registered with PROSPERO (CRD42020205207) and reported according to PRISMA guidelines. We searched Medline, EMBASE, Web of Science, CINAHL, and Cochrane Library on October 6, 2021. Two investigators screened titles and abstracts, extracted data, and assessed risks of bias using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) template. We estimated sensitivity and specificity when feasible and evaluated the certainty of evidence with Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.Of 8,621 search results, 12 observational studies reported 26 combinations of index tests and reference standards to indicate six different etiologies of cardiac arrest. All studies had high risks of bias from subject selection, lack of blinding, reference standards susceptible to confounding, and/or differential verification. One study reported sufficient data to complete contingency tables for sensitivity and specificity of POCUS to identify myocardial infarction, cardiac tamponade, and pulmonary embolism as the etiology of cardiac arrest. Heterogeneity and risk of bias precluded meta-analysis and the certainty of evidence was uniformly very low.It is feasible to identify reversible causes of cardiac arrest with POCUS, but the current literature is heterogenous with high risks of bias, wide confidence intervals, and very low certainty of evidence, which render these data difficult to interpret.

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations for advanced life support includes updates on multiple advanced life support topics addressed with 3 different types of reviews. Topics were prioritized on the basis of both recent interest within the resuscitation community and the amount of new evidence available since any previous review. Systematic reviews addressed higher-priority topics, and included double-sequential defibrillation, intravenous versus intraosseous route for drug administration during cardiac arrest, point-of-care echocardiography for intra-arrest prognostication, cardiac arrest caused by pulmonary embolism, postresuscitation oxygenation and ventilation, prophylactic antibiotics after resuscitation, postresuscitation seizure prophylaxis and treatment, and neuroprognostication. New or updated treatment recommendations on these topics are presented. Scoping reviews were conducted for anticipatory charging and monitoring of physiological parameters during cardiopulmonary resuscitation. Topics for which systematic reviews and new Consensuses on Science With Treatment Recommendations were completed since 2015 are also summarized here. All remaining topics reviewed were addressed with evidence updates to identify any new evidence and to help determine which topics should be the highest priority for systematic reviews in the next 1 to 2 years.

Objective To determine if arterial oxygen and carbon dioxide abnormalities in the first 24 h after return of spontaneous circulation (ROSC) are associated with increased mortality in adult out-of-hospital cardiac arrest (OHCA). Methods We used data from the Resuscitation Outcomes Consortium (ROC), including adult OHCA with sustained ROSC ≥1 h after Emergency Department arrival and at least one arterial blood gas (ABG) measurement. Among ABGs measured during the first 24 h of hospitalization, we identified the presence of hyperoxemia (PaO2 ≥ 300 mmHg), hypoxemia (PaO2 50 mmHg) and hypocarbia (PaCO2 Results Among 9186 OHCA included in the analysis, hospital mortality was 67.3%. Hyperoxemia, hypoxemia, hypercarbia, and hypocarbia occurred in 26.5%, 19.0%, 51.0% and 30.6%, respectively. Initial hyperoxemia only was not associated with hospital mortality (adjusted OR 1.10; 95% CI: 0.97–1.26). However, final and any hyperoxemia (1.25; 1.11–1.41) were associated with increased hospital mortality. Initial (1.58; 1.30–1.92), final (3.06; 2.42–3.86) and any (1.76; 1.54–2.02) hypoxemia (PaO2 50 mmHg) were associated with increased hospital mortality. Initial (1.13; 0.90–1.41), final (1.19; 1.04–1.37) and any (1.01; 0.91–1.12) hypocarbia (PaCO2 Conclusions In the first 24 h after ROSC, abnormal post-arrest oxygen and carbon dioxide tensions are associated with increased out of-hospital cardiac arrest mortality.

Background Despite increasing evidence for specialized cardiac arrest centers, the impact of transport time on out-of-hospital cardiac arrest (OHCA) patients’ outcome remains unclear. We systematically reviewed the prognostic impact of transport time in OHCA patients. Methods We searched PubMed, Embase, the Cochrane Library, and Web of Science from inception to May 2016 for studies that had reported the relationship between transport time and outcome in OHCA patients. The primary outcome was survival at hospital discharge. The secondary outcomes included neurological outcome at hospital discharge and long-term outcome. Results From a total of 3454 titles retrieved from the literature search, 9 studies were included for final analysis. All nine studies (N = 46,417) were retrospective observational studies. OHCA patients included were mostly male (61–76%), suffered a witnessed cardiac arrest in half of the cases, and had an initial shockable rhythm in one third of cases. The overall survival to hospital discharge for all cardiac rhythms was less than 6%. There was no evidence for a differential mortality risk in OHCA patients according to transport time (mean difference −0.05 min [−0.86,0.76]; I2 25%; 4 studies, 2197 patients). Conclusion Paramedic transport time was not associated with survival to hospital discharge or with neurological outcome at hospital discharge in adult OHCA patients. Future studies are needed to prospectively evaluate the prognostic impact of transport time particularly in rural settings and pediatric population.

Sudden cardiac arrest (SCA), confirmed absence of cardiac mechanical activity, is the leading cause of heart-related death in the US. Almost 85% of SCA occur out-of-hospital (OHCA), with very poor rates of return of spontaneous circulation (ROSC) and survival to hospital discharge. We sought to determine if diabetes status was associated with survival or ROSC following an OHCA.We completed a retrospective cohort study using data from the Toronto Regional RescuNet Epistry dataset, based upon data definitions defined by the Resuscitation Outcomes Consortium (ROC) Epistry-Cardiac Arrest and the Strategies for Post Arrest Resuscitation Care (SPARC) network datasets. Adults ≥18years of age who experienced an OHCA, had data on diabetes status, and were treated by Emergency Medical Services (EMS) between 2012-2014 were included in the analysis (n=10,097). We used bivariate analyses to examine relationships between diabetes status, Utstein elements and outcomes, and logistic regression to determine predictors of survival.Diabetes prevalence was 27.8% (95% CI: 27.0-28.7). A larger proportion of those with diabetes had a non-shockable initial rhythm (28.8% vs. 25.1%; p0.01) and did not survive to hospital discharge (92.1% vs. 89.2%, p0.001). Diabetes status is associated with a decrease in survival, independent from a number of Utstein elements (adjusted OR=0.76; 95% CI: 0.64-0.91, p=0.003).This is the first Canadian study to examine the association between diabetes status and OHCA outcomes. Our findings suggest that diabetes status prior to arrest is associated with decreased survival. The growing prevalence of diabetes globally suggests a future burden related to OHCAs.

Introduction The Universal Termination of Resuscitation (TOR) Guideline accurately identifies potential out-of-hospital cardiac arrest (OHCA) survivors. However, implementation is inconsistent with some Emergency Medical Service (EMS) agencies using absence of return of spontaneous circulation (ROSC) as sole criterion for termination. Objective To compare the performance of the Universal TOR Guideline with the single criterion of no prehospital ROSC. Second, to determine factors associated with survival for patients transported without a ROSC. Lastly, to compare the impact of time to ROSC as a marker of futility to the Universal TOR Guideline. Design Retrospective, observational cohort study. Participants Non-traumatic, adult (≥18 years) OHCA patients of presumed cardiac etiology treated by EMS providers. Setting ROC-PRIMED and ROC-Epistry post ROC-PRIMED databases between 2007 and 2011. Outcomes Primary outcome was survival to hospital discharge and the secondary outcome was functional survival. We used multivariable regression to evaluate factors associated with survival in patients transported without a ROSC. Results 36,543 treated OHCAs occurred of which 9467 (26%) were transported to hospital without a ROSC. Patients transported without a ROSC who met the Universal TOR Guideline for transport had a survival of 3.0% (95% CI 2.5–3.4%) compared to 0.7% (95% CI 0.4–0.9%) in patients who met the Universal TOR Guideline for termination. The Universal TOR Guideline identified 99% of survivors requiring continued resuscitation and transportation to hospital including early identification of survivors who sustained a ROSC after extended durations of CPR. Conclusion Using absence of ROSC as a sole predictor of futility misses potential survivors. The Universal TOR Guideline remains a strong predictor of survival.

International audience; Introduction: Bag-valve-mask ventilation is the first-line ventilation method during cardiopulmonary resuscitation (CPR). Risks include excessive volume delivery and gastric insufflation, the latter increasing the risk of pneumonia. The efficacy of ventilation can also be reduced by airway closure. We hypothesized that continuous chest compression (CC) could limit the risk of gastric insufflation compared to the recommended 30:2 interrupted CC strategy. This experimental study was performed in human "Thiel" cadavers to assess the respective impact of discontinuous vs. continuous chest compressions on gastric insufflation and ventilation during CPR.Methods: The 30:2 interrupted CC technique was compared to continuous CC in 5 non-intubated cadavers over a 6 min-period. Flow and Airway Pressure were measured at the mask. A percutaneous gastrostomy allowed measuring the cumulative gastric insufflated volume. Two additional cadavers were equipped with esophageal and gastric catheters instead of the gastrostomy.Results: For the 7 cadavers studied (4 women) median age of death was 79 [74-84] years. After 6 min of CPR, the cumulative gastric insufflation measured in 5 cadavers was markedly reduced during continuous CC compared to the interrupted CC strategy: (1.0 [0.8-4.1] vs. 5.9 [4.0-5.6] L; p < 0.05) while expired minute ventilation was slightly higher during continuous than interrupted CC (1.9 [1.4-2.8] vs. 1.6 [1.1-2.7] L/min; P < 0.05). In 2 additional cadavers, the progressive rise in baseline gastric pressure was lower during continuous CC than interrupted CC (1 and 2 cmH2O vs. 12 and 5.8 cmH2O).Conclusion: Continuous CC significantly reduces the volume of gas insufflated in the stomach compared to the recommended 30:2 interrupted CC strategy. Ventilation actually delivered to the lung is also slightly increased by the strategy.

AIM: To systematically review the literature on the use of vasopressors during adult cardiac arrest to inform an update of international guidelines.METHODS: PRISMA guidelines were followed. We searched Medline, Embase, Web of Science, CINAHL, and the Cochrane Library for controlled trials and observational studies. The population included adults with cardiac arrest in any setting. Pairs of investigators reviewed studies for relevance, extracted data, and assessed the risk of bias for individual studies. Certainty of evidence was evaluated using GRADE for controlled trials and meta-analyses were performed when at least two studies could be pooled.RESULTS: We included 15 controlled trials and 67 observational studies. The majority of studies included out-of-hospital cardiac arrest only. Meta-analyses were performed for two controlled trials comparing epinephrine to placebo, three comparing vasopressin to epinephrine, and three comparing epinephrine plus vasopressin to epinephrine only. All controlled trials ranged between low to some concern in risk of bias. The certainty of evidence ranged from very low to high. Risk of bias for observational studies was generally critical or serious, largely due to confounding and selection bias.CONCLUSIONS: Controlled trial data suggest that epinephrine improves return of spontaneous circulation, survival to hospital discharge, and 3-month survival in out-of-hospital cardiac arrest, with a stronger magnitude of effect for non-shockable rhythms compared to shockable rhythms. Differences in long-term neurological outcome did not reach statistical significance, although there was a signal toward improved outcomes. Controlled trial data indicated no benefit from vasopressin with or without epinephrine compared to epinephrine only.

The role of chest compression fraction (CCF) in resuscitation of shockable out-of-hospital cardiac arrest (OHCA) is uncertain. We evaluated the relationship between CCF and clinical outcomes in a secondary analysis of the Resuscitation Outcomes Consortium PRIMED trial.We included patients presenting in a shockable rhythm who suffered OHCA prior to EMS arrival. Multivariable logistic regression was used to determine the relationship between CCF and survival to hospital discharge, return of spontaneous circulation (ROSC), and neurologically intact survival. We also performed a secondary analysis restricted to patients without ROSC in the first 10 min of EMS resuscitation.Among the 2011 patients, median (IQR) age was 65 (54, 75) years, 78.2% were male, and mean (SD) CCF was 0.71 (0.14). Compared to the reference group (CCF0.60), the odds ratio (OR) for survival was 0.49 (95% CI: 0.36, 0.68) for CCF 0.60-0.79 and 0.30 (95% CI: 0.20, 0.44) for CCF≥0.80. Results were similar for outcomes of ROSC and neurologically intact survival. Conversely, when restricted to the cohort who did not achieve ROSC during the first 10 min (n=1633), compared to the reference group (CCF0.60), the OR for survival was 0.79 (95% CI: 0.53, 1.18) for CCF 0.60-0.79 and OR 0.88 (95% CI: 0.56, 1.36) for CCF≥0.80.In this study of OHCA patients presenting in a shockable rhythm, CCF was paradoxically associated with lower odds of survival. CCF is a complex measure and taken by itself may not be a consistent predictor of good clinical outcomes.

High-quality cardiopulmonary resuscitation (CPR) may improve survival. The quality of CPR performed during pediatric out-of-hospital cardiac arrest (p-OHCA) is largely unknown. The main objective of this study was to describe the quality of CPR performed during p-OHCA resuscitation attempts.Prospective observational multi-center cohort study of p-OHCA patients ≥ 1 and19 years of age registered in the Resuscitation Outcomes Consortium (ROC) Epistry database. The primary outcome was an a priori composite variable of compliance with American Heart Association (AHA) guidelines for both chest compression (CC) rate and CC fraction (CCF). Event compliance was defined as a case with 60% or more of its minute epochs compliant with AHA targets (rate 100-120 min(-1); depth ≥ 38 mm; and CCF ≥ 0.80). In a secondary analysis, multivariable logistic regression was used to evaluate the association between guideline compliance and return of spontaneous circulation (ROSC).Between December 2005 and December 2012, 2564 pediatric events were treated by EMS providers, 390 of which were included in the final cohort. Of these events, 22% achieved AHA compliance for both rate and CCF, 36% for rate alone, 53% for CCF alone, and 58% for depth alone. Over time, there was a significant increase in CCF (p0.001) and depth (p = 0.03). After controlling for potential confounders, there was no significant association between AHA guideline compliance and ROSC.In this multi-center study, we have established that there are opportunities for professional rescuers to improve prehospital CPR quality. Encouragingly, CCF and depth both increased significantly over time.

Measures of chest compression fraction (CCF), compression rate, compression depth and pre-shock pause have all been independently associated with improved outcomes from out-of-hospital (OHCA) cardiac arrest. However, it is unknown whether compliance with American Heart Association (AHA) guidelines incorporating all the aforementioned metrics, is associated with improved survival from OHCA.We performed a secondary analysis of prospectively collected data from the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest database. As per the 2015 American Heart Association (AHA) guidelines, guideline compliant cardiopulmonary resuscitation (CPR) was defined as CCF0.8, chest compression rate 100-120/minute, chest compression depth 50-60mm, and pre-shock pause10s. Multivariable logistic regression models controlling for Utstein variables were used to assess the relationship between global guideline compliance and survival to hospital discharge and neurologically intact survival with MRS ≤3. Due to potential confounding between CPR quality metrics and cases that achieved early ROSC, we performed an a priori subgroup analysis restricted to patients who obtained ROSC after ≥10min of EMS resuscitation.After allowing for study exclusions, 19,568 defibrillator records were collected over a 4-year period ending in June 2015. For all reported models, the reference standard included all cases who did not meet all CPR quality benchmarks. For the primary model (CCF, rate, depth), there was no significant difference in survival for resuscitations that met all CPR quality benchmarks (guideline compliant) compared to the reference standard (OR 1.26; 95% CI: 0.80, 1.97). When the dataset was restricted to patients obtaining ROSC after ≥10min of EMS resuscitation (n=4,158), survival was significantly higher for those resuscitations that were guideline compliant (OR 2.17; 95% CI: 1.11, 4.27) compared to the reference standard. Similar findings were obtained for neurologically intact survival with MRS ≤3 (OR 3.03; 95% CI: 1.12, 8.20).In this observational study, compliance with AHA guidelines for CPR quality was not associated with improved outcomes from OHCA. Conversely, when restricting the cohort to those with late ROSC, compliance with guidelines was associated with improved clinical outcomes. Strategies to improve overall guideline compliance may have a significant impact on outcomes from OHCA.

Background Cardiac arrest physiology has been proposed to occur in three distinct phases: electrical, circulatory and metabolic. There is limited research evaluating the relationship of the 3-phase model of cardiac arrest to functional survival at hospital discharge. Furthermore, the effect of post-cardiac arrest targeted temperature management (TTM) on functional survival during each phase is unknown. Objective To determine the effect of TTM on the relationship between the time of initial defibrillation during each phase of cardiac arrest and functional survival at hospital discharge. Methods This was a retrospective observational study of consecutive adult (≥18 years) out-of-hospital cardiac arrest (OHCA) patients with initial shockable rhythms. Included patients obtained a return of spontaneous circulation (ROSC) and were eligible for TTM. Multivariable logistic regression was used to determine predictors of functional survival at hospital discharge. Results There were 20,165 OHCA treated by EMS and 871 patients were eligible for TTM. Of these patients, 622 (71.4%) survived to hospital discharge and 487 (55.9%) had good functional survival. Good functional survival was associated with younger age (OR 0.94; 95% CI 0.93–0.95), shorter times from collapse to initial defibrillation (OR 0.73; 95% CI 0.65–0.82), and use of post-cardiac arrest TTM (OR 1.49; 95% CI 1.07–2.30). Functional survival decreased during each phase of the model (65.3% vs. 61.7% vs. 50.2%, P Conclusion Functional survival at hospital discharge was associated with shorter times to initial defibrillation and was decreased during each successive phase of the 3-phase model. Post-cardiac arrest TTM was associated with improved functional survival.

Background Previous studies have demonstrated significant associations between cardiopulmonary resuscitation (CPR) quality metrics and survival to hospital discharge. No adequately powered study has explored the relationship between location of resuscitation (scene vs. transport) and CPR quality. Methods We analyzed CPR quality data from treated adult OHCA occurring over a 40 month period beginning January 1, 2013 from the Rescu Epistry-cardiac arrest database. High quality CPR was defined as chest compression fraction (CCF) >0.7, compression rate >100/min and compression depth >5.0 cm. Our primary objective was to compare the proportion of resuscitations for which all CPR quality benchmarks were met between scene and transport phases of resuscitation. Our secondary objectives were to compare the quality of CPR between the scene phase and transport phase of resuscitation. Results The proportion of patients with high quality CPR was similar on scene compared to during transport (45.8% vs. 42.5%; ∆ 3.3 %; 95% CI: −1.4, 8.1). Regarding individual CPR metrics, median compression rate was higher on scene compared to transport (105.8 compressions per minute (cpm) vs. 102.0 cpm; ∆ 3.8 cpm; 95% CI: 2.5, 4.0), while median compression depth (5.56 cm vs. 5.33 cm; ∆ 0.23 cm; 95% CI: 0.12, 0.26) and median CCF (0.95 vs. 0.87; ∆ 0.08; 95% CI: 0.07, 0.08) were higher during the transport phase. Conclusions High quality CPR metrics were similar in both (scene and transport) locations of resuscitation. These results suggest that high quality, manual compressions can be performed by prehospital providers regardless of location.

Pre-shock pause duration of20s is associated with improved survival after cardiac arrest. Manual mode defibrillation has been associated with the shortest duration of pre-shock pause but is largely practiced by advanced life support paramedics (ALS) whereas defibrillator only paramedics (basic life support or BLS) routinely use the defibrillator in automatic mode.We sought to explore the relationship between manual mode defibrillation, pre-shock pause duration and rate of inappropriate shocks when defibrillation is provided by ALS vs. BLS trained in manual mode defibrillation.We performed a retrospective review of all treated non-traumatic adult out-of-hospital cardiac arrest (OHCA) presenting in a shockable rhythm over a one year period beginning January 1, 2012. Our primary outcome measure was the proportion of manual mode shocks delivered by BLS with pre-shock pause duration of20s when compared to ALS. Our secondary outcome measures were the duration of pre-, post- and peri-shock pause and the proportion of appropriate shocks (defined as correct identification and shock delivery to patients in a shockable rhythm) delivered by either level of paramedic. This study had a power of 90% to detect an absolute difference of 15% between paramedic levels in proportion of shocks delivered with pre-shock pause duration20s.Among 2019 treated OHCA, 335 (20%) presented in a shockable rhythm. Manual defibrillation was performed in 155 (46%) of these cases (196 shocks by ALS, 143 shocks by BLS). There were no differences in the proportion of shocks delivered with pre-shock pause duration20s (ALS 82.8% vs. BLS 84.8%, p=.65) nor pre-shock pause duration (s) (median, Q1, Q3); ALS: 12.0 (7.0,17.0) vs. BLS: 11.0 (5.0,17.0), p=.13 while BLS had a significantly shorter peri-shock pause duration (s) (median, Q1, Q3); ALS: 17.0 (12.0, 23.0) vs. BLS: 15.0 (9.0, 22.0), p=.05. There were no differences in the rate of inappropriate shocks (ALS 1.0% vs. BLS 0.7%), p=1.0 between levels of paramedics.Manual mode defibrillation by BLS paramedics produced similar measures of pre-shock pause duration when compared to ALS paramedics without increasing the incidence of inappropriate shocks. Further study is required to determine the potential impact of BLS manual mode defibrillation on clinical outcomes.

Background Some Emergency Medical Services currently use just one component of the Universal Termination of Resuscitation (TOR) Guideline, the absence of prehospital return of spontaneous circulation (ROSC), as the single criteria to terminate resuscitation, which may deny transport to potential survivors. Objective This study aimed to report the survival to hospital discharge rate in non-traumatic, adult out-of-hospital cardiac arrest (OHCA) patients transported to hospital without a prehospital ROSC. Methods An observational study of OHCA patients without a prehospital ROSC who met the Universal TOR Guideline for transport to hospital with ongoing resuscitation. Multivariable logistic regression was used to determine the association of each variable with survival to hospital discharge. Results Of 20,207 OHCA treated by EMS, 3374 (16.4%) did not have a prehospital ROSC but met the Universal TOR guideline for transport to hospital with ongoing resuscitation. Of these patients, 122 (3.6%) survived to hospital discharge. Survival to discharge was associated with initial shockable VF/VT rhythms (OR 5.07; 95% CI 2.77–9.30), EMS-witnessed arrests (OR 3.51; 95% CI 1.73–7.15), bystander-witnessed arrests (OR 2.11; 95% CI 1.18–3.77), and public locations (OR 1.57; 95% CI 1.02–2.40). Conclusion In OHCA patients without a prehospital ROSC who met the Universal TOR Guideline for transport with ongoing resuscitation survival rates were above the 1% futility rate. Employing only the lack of ROSC as criteria for termination of resuscitation may miss survivors after OHCA.