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Purpose We examined changes in annual paramedic transport incidence over the ten years prior to COVID-19 in comparison to increases in population growth and emergency department (ED) visitation by walk-in. Methods We conducted a population-level cohort study using the National Ambulatory Care Reporting System from January 1, 2010 to December 31, 2019 in Ontario, Canada. We included all patients triaged in the ED who arrived by either paramedic transport or walk-in. We clustered geographical regions using the Local Health Integration Network boundaries. Descriptive statistics, rate ratios (RR), and 95% confidence intervals were calculated to explore population-adjusted changes in transport volumes. Results Overall incidence of paramedic transports increased by 38.3% (n = 264,134), exceeding population growth fourfold (9.4%) and walk-in ED visitation threefold (13.4%). Population-adjusted transport rates increased by 26.2% (rate ratio 1.26, 95% CI 1.26–1.27) compared to 3.4% for ED visit by walk-in (rate ratio 1.03, 95% CI 1.03–1.04). Patient and visit characteristics remained consistent (age, gender, triage acuity, number of comorbidities, ED disposition, 30-day repeat ED visits) across the years of study. The majority of transports in 2019 had non-emergent triage scores (60.0%) and were discharged home directly from the ED (63.7%). The largest users were persons aged 65 or greater (43.7%). The majority of transports occurred in urbanized regions, though rural and northern regions experienced similar paramedic transport growth rates. Conclusion There was a substantial increase in the demand for paramedic transportation. Growth in paramedic demand outpaced population growth markedly and may continue to surge alongside population aging. Increases in the rate of paramedic transports per population were not bound to urbanized regions, but were province-wide. Our findings indicate a mounting need to develop innovative solutions to meet the increased demand on paramedic services and to implement long-term strategies across provincial paramedic systems.

his is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed. This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

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.

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.

SARS-CoV-2 represents an occupational risk to paramedics, who work in uncontrolled environments. We sought to identify the occupation-specific risk to paramedics by comparing their seroprevalence of SARS-CoV-2 infection-specific antibodies to that of blood donors in Canada.In this prospective cohort study, we performed serology testing (Elecsys Anti-SARS-CoV-2 nucleocapsid assay) on samples from paramedics and blood donors (January to July 2021) in Canada. Paramedic samples were compared to blood donor samples through 1:1-matched (based on age, sex, location, date of blood collection, and vaccination status) and raking weighted comparisons. We compared the seroprevalence with a risk difference (and 95% confidence interval [CI]) and performed secondary analyses within subgroups defined by vaccination status.The 1:1 match included 1,627 cases per group; in both groups, 723 (44%) were women, with a median age of 38. The raking weighted comparison included 1,713 paramedic samples and 19,515 blood donor samples, with similar characteristics. In the 1:1 match, the seroprevalence was similar (difference 1.2; 95% CI -0.20 to 2.7) between paramedics (5.2%) and blood donors (3.9%). The raking weighted comparison was consistent (difference 0.97; 95% CI -0.10 to 2.0). The unvaccinated paramedic samples, in comparison to the blood donor samples, demonstrated a higher seroprevalence in the 1:1 (difference 5.9; 95% CI 1.8 to 10) and weighted (difference 6.5; 95% CI 1.8 to 10) comparisons. Among vaccinated cases, the between-group seroprevalence was similar.Overall, paramedics demonstrated similar evidence of prior SARS-CoV-2 infection to that of blood donors. However, among unvaccinated individuals, evidence of prior infection was higher among paramedics compared to blood donors.

Near-infrared spectroscopy (NIRS) provides continuous real-time measurement of regional cerebral oxygen saturation (rSO2) during resuscitation. We aimed to evaluate the feasibility of paramedics using NIRS during out-of-hospital cardiac arrest (OHCA) resuscitation. Paramedics were trained to record rSO2 and mark events during resuscitation. Feasibility was defined as > 70% of cases with rSO2 data and event markers. The monitor was applied on 23 patients with OHCA. Of these, 19 (83%) had rSO2 data (median duration of 17.9 minutes; interquartile range, 9.7-28) and 17 (74%) had event markers (median 3 events per case; interquartile range, 1-4). It is feasible for paramedics to apply NIRS during OHCA resuscitation. Résumé: La spectroscopie proche infrarouge (NIRS, de l’anglais near-infrared spectroscopy) fournit une mesure continue en temps réel de la saturation cérébrale régionale en oxygène (rSO2) pendant la réanimation. Notre but était d’évaluer la faisabilité de l’utilisation de la NIRS par le personnel paramédical au cours de la réanimation d’un arrêt cardiaque extrahospitalier. Des intervenants paramédicaux ont appris à enregistrer la rSO2 et les marqueurs d’événements pendant une réanimation. La faisabilité a été définie comme l’obtention de données sur la rSO2 et de marqueurs d’événements dans plus de 70 % des cas. Ces intervenants médicaux ont utilisé le moniteur chez 23 patients en arrêt cardiaque extrahospitalier. Ils ont recueilli des données sur la rSO2 chez 19 (83 %) de ces patients (durée médiane de 17,9 minutes; écart interquartile : de 9,7 à 28) et des marqueurs d’événements chez 17 (74 %) (médiane de 3 événements par cas; écart interquartile : de 1 à 4). Il est faisable pour le personnel paramédical d’utiliser la NIRS au cours de la réanimation d’un arrêt cardiaque extrahospitalier.

Background Early coronary angiography (CAG) has been reported in individual studies and systematic reviews to significantly improve outcomes of patients with return of spontaneous circulation (ROSC) after cardiac arrest (CA). Methods We undertook a systematic review and meta-analysis to evaluate the impact of early CAG on key clinical outcomes in comatose patients after ROSC following out-of-hospital CA of presumed cardiac origin. We searched the PubMED, EMBASE, CINAHL, ERIC and Cochrane Central Register of Controlled Trials databases from 1990 until April 2020. Eligible studies compared patients undergoing early CAG to patients with late or no CAG. When randomized controlled trials (RCTs) existed for a specific outcome, we used their results to estimate the effect of the intervention. In the absence of randomized data, we used observational data. We excluded studies at high risk of bias according to the Robins-I tool from the meta-analysis. The GRADE system was used to assess certainty of evidence at an outcome level. Results Of 3738 citations screened, 3 randomized trials and 41 observational studies were eligible for inclusion. Evidence certainty across all outcomes for the RCTs was assessed as low. Randomized data showed no benefit from early as opposed to late CAG across all critical outcomes of survival and survival with favourable neurologic outcome for undifferentiated patients and for patient subgroups without ST-segment-elevation on post ROSC ECG and shockable initial rhythm. Conclusion These results do not support routine early CAG in undifferentiated comatose patients and patients without STE on post ROSC ECG after OHCA. Review registration PROSPERO — CRD42020160152.

Introduction: Drone-delivered defibrillators may reduce response time for out-of-hospital cardiac arrest (OHCA). However, an optimal dispatch rule is not yet known. Methods: We identified all suspected OHCAs in Peel Region, Ontario, Canada from Jan. 2014 to Dec. 2019. We trained a neural network model to predict emergency medical services (EMS) response times using OHCA location, distance from responding ambulance, day of week and time of day. Instead of least-squares loss, our model optimized a loss function that penalized weighted errors in the dispatch decision (type I/II error). Assuming drones were deployed from three bases in the region, we calculated drone response time to each suspected OHCA using real drone specifications. Our dispatch rule dispatched a drone when its calculated response time was shorter than the predicted EMS response time. Response time was calculated as the minimum of the drone and EMS response times. The performance of our dispatch rule was compared on out-of-sample OHCAs using 5-fold cross validation to the baseline cases of (1) no drones, and (2) drone dispatch to every suspected OHCA. Statistical analysis on the median response times was performed using a right-tailed sign test. Results: We identified 4774 suspected OHCAs with a median historical EMS response time of 6.0 minutes. Using our dispatch rule, median response time was significantly shorter at 3.9 minutes (P Conclusion: A machine learning-based dispatch rule can achieve similar response times as a policy that dispatches a drone to all suspected OHCAs, while dispatching drones less frequently.

Introduction: Prognostication is a significant challenge early in the post-cardiac arrest period. Common prognostic factors for neurological survival are unreliable (high false positive rates) until 72 hours post-cardiac arrest. It is not known whether there are a combination of factors that can be utilized earlier in the post-cardiac arrest period to accurately predict patient outcome. Our objective was to predict neurological outcome utilizing a novel combination of patient factors early in the post-cardiac arrest period. Methods: We conducted a retrospective cohort study using data from our local registry. We included adult patients who obtained a return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA). We excluded patients who did not survive for at least 24 hours post-ROSC and those who had a do not resuscitate (DNR) order within 2 hours of ROSC. We performed an ordinal regression analysis using the proportional odds model to predict neurological outcome (modified rankin score (mRS)). We included a good neurological outcome (mRS 0-2), poor neurological outcome (mRS 3-5), and dead (mRS 6) as an ordinal outcome. We included a number of patient demographics, intra- and post-cardiac arrest factors as covariates in our model. The predictive performance of our model was analyzed using receiver operating characteristic (ROC) curves for discrimination and Brier statistic for calibration. Results: We included 3448 patients in our analysis. We found that an initial shockable rhythm (odds ratio (OR) 4.1; 95% confidence interval (CI) 3.6, 5.4), the absence of pupillary reflexes (OR 3.5; 95% CI 2.4,4.8) and maximum motor score on the Glasgow Coma Scale (GCS) (OR 1.5; 95% CI 1.4,1.6) had the greatest association with improved neurologic outcome. Longer duration of resuscitation was associate with worse outcomes (OR 0.84, 95% CI 0.82,0.87). The overall performance of our model was excellent with an area under the ROC curve of 0.89 and a Brier statistic of 0.13. Conclusion: Our model predicted good neurological outcome with a high rate of accuracy, however external validation of the model is required. This model may be useful to provide risk stratification of patients in clinical practice and future research on post-cardiac arrest care.

Background: There is substantial regional variation in out-of-hospital cardiac arrest (OHCA) outcomes. We investigated whether regional-level intra-arrest transport practices were associated with patient outcomes. Methods: We performed a secondary analysis of the “CCC Trial” dataset, which included EMS-treated adult non-traumatic OHCA enrolled from 49 regional clusters. The exposure of interest was regional-level intra-arrest transport practices (RIATP), calculated as the proportion of cases within the enrolling cluster transported prior to return of spontaneous circulation (“intra-arrest transport”), divided into quartiles. We fit a multilevel mixed-effects logistic regression model to estimate the association of RIATP quartile and both survival and favorable neurologic status (mRS ≤ 3) at hospital discharge, adjusted for patient-level Utstein variables. Results: We included all 26,148 CCC-enrolled patients, 36% of whom were female, 97% were treated with prehospital ALS, and 23% had shockable initial rhythms. The median RIATP of the 49 clusters was 20% (IQR 6.2 - 30%). The figure shows outcomes stratified by RIATP quartile. Compared to the first quartile ( Conclusion: Treatment within a region that utilizes intra-arrest transport less frequently was associated with improved patient survival. These results may, in part, explain differences between regional OHCA survival outcomes.

Background Time to treatment is critical for survival from sudden cardiac arrest. Every minute delay in defibrillation results in a 7% to 10% reduction in survival. This is particularly problematic in rural and remote regions, where emergency medical service response is prolonged and automated external defibrillators ( AEDs ) are often not available. Our primary objective was to examine the feasibility of a novel AED drone delivery method for rural and remote sudden cardiac arrest. A secondary objective was to compare response times between AED drone delivery and ambulance to mock sudden cardiac arrest resuscitations. Methods and Results We conducted 6 simulations in 2 rural communities in southern Ontario, Canada. In the first 2 simulations, the drone and ambulance were dispatched from the same paramedic base. In simulations 3 and 4, the drone and ambulance were dispatched from separate paramedic bases; and in simulations 5 and 6, the drone was dispatched from an optimized location. During each simulation, a “mock” call was placed to 911 and a single AED drone and an ambulance were simultaneously dispatched to a predetermined destination. On scene, trained first responders retrieved the AED from the drone and initiated resuscitative efforts on a mannequin until paramedics arrived. No difficulties were encountered during drone activation by dispatch, ascent, landing, or bystander retrieval of the AED from the drone. During simulations 1 and 2, the distance to the scene was 6.6 km. For simulations 3 and 4, the ambulance response distance increased to 8.8 km while drone remained at 6.6 km; and in simulations 5 and 6, the ambulance response distance was 20 km compared with 9 km for the drone. During each flight, the AED drone arrived on scene before the ambulance, between 1.8 and 8.0 minutes faster. Conclusions This study suggests AED drone delivery is feasible, with the potential for improvements in response time during simulated sudden cardiac arrest scenarios. Further research is required to determine the appropriate system configuration for AED drone delivery in an integrated emergency medical service system as well as optimal strategies to simplify bystander application of a drone‐delivered AED .

To assess the individual and community health effects of task shifting for emergency care in low-resource settings and underserved populations worldwide.We systematically searched 13 databases and additional grey literature for studies published between 1984 and 2019. Eligible studies involved emergency care training for laypeople in underserved or low-resource populations, and any quantitative assessment of effects on the health of individuals or communities. We conducted duplicate assessments of study eligibility, data abstraction and quality. We synthesized findings in narrative and tabular format.Of 19 308 papers retrieved, 34 studies met the inclusion criteria from low- and middle-income countries (21 studies) and underserved populations in high-income countries (13 studies). Targeted emergency conditions included trauma, burns, cardiac arrest, opioid poisoning, malaria, paediatric communicable diseases and malnutrition. Trainees included the general public, non-health-care professionals, volunteers and close contacts of at-risk populations, all trained through in-class, peer and multimodal education and public awareness campaigns. Important clinical and policy outcomes included improvements in community capacity to manage emergencies (14 studies), patient outcomes (13 studies) and community health (seven studies). While substantial effects were observed for programmes to address paediatric malaria, trauma and opioid poisoning, most studies reported modest effect sizes and two reported null results. Most studies were of weak (24 studies) or moderate quality (nine studies).First aid education and task shifting to laypeople for emergency care may reduce patient morbidity and mortality and build community capacity to manage health emergencies for a variety of emergency conditions in underserved and low-resource settings.Évaluer l'impact, sur la santé individuelle et collective, du transfert des interventions de premiers secours dans les endroits disposant de ressources limitées et au sein des populations défavorisées à travers le monde.Nous avons analysé systématiquement 13 bases de données ainsi que toute littérature grise complémentaire pour y trouver des études publiées entre 1984 et 2019. Les études retenues devaient faire mention d'une formation aux premiers secours pour les non-professionnels au sein des populations défavorisées ou dotées de peu de ressources, mais aussi d'une évaluation quantitative de l'impact sur la santé individuelle et collective. Nous avons dupliqué les appréciations d'admissibilité de l'étude, de qualité et d'abstraction des données. Enfin, nous avons synthétisé les résultats sous forme de textes et de tableaux.Sur 19 308 articles récupérés, 34 études correspondaient aux critères d'inclusion propres aux pays à faibles et moyens revenus (21 études) et aux populations défavorisées dans les pays à hauts revenus (13 études). Plusieurs situations d'urgence étaient ciblées: traumatismes, brûlures, arrêts cardiaques, intoxications aux opiacés, malaria, maladies infantiles contagieuses et malnutrition. Les stagiaires étaient des individus issus du grand public, des non-professionnels de la santé, des bénévoles et des contacts proches de populations à risque, tous formés dans le cadre de cours multimodaux organisés par des pairs et de campagnes de sensibilisation de l'opinion publique. Diverses retombées politiques et cliniques d'envergure ont été constatées: amélioration de la capacité de gestion des urgences dans les communautés (14 études), conséquences positives pour les patients (13 études) et santé collective (7 études). Bien que des effets non négligeables aient été observés pour les programmes de lutte contre la malaria infantile, les traumatismes et l'intoxication aux opiacés, la plupart des études n'ont remarqué que des effets d'ampleur modeste et deux ont rapporté un bénéfice nul. En outre, la majorité d'entre elles se sont révélées de piètre qualité (24 études) ou de qualité moyenne (9 études).La formation aux premiers secours et le transfert des interventions aux non-professionnels peut contribuer à diminuer la morbidité et la mortalité des patients, mais aussi à développer les capacités communautaires de gestion des urgences sanitaires pour une série de situations dans les milieux défavorisés ou manquant de ressources.Evaluar los efectos en la salud individual y comunitaria del cambio de tareas para la atención de emergencia en entornos con bajos recursos y poblaciones desatendidas a nivel mundial.Se realizaron búsquedas sistemáticas en 13 bases de datos y en la literatura gris adicional de estudios publicados entre 1984 y 2019. Los estudios elegibles involucraron la formación en atención de emergencia para personas no profesionales en poblaciones subatendidas o de bajos recursos, y cualquier evaluación cuantitativa de los efectos en la salud de los individuos o las comunidades. Se realizaron evaluaciones duplicadas de la elegibilidad de los estudios, la abstracción de datos y la calidad. Se sintetizaron los resultados en formato narrativo y tabular.De los 19.308 documentos recuperados, 34 estudios cumplían los criterios de inclusión de países con ingresos bajos y medios (21 estudios) y de poblaciones desatendidas de países con ingresos altos (13 estudios). Las condiciones de emergencia a las que se dirigían incluían traumatismos, quemaduras, paros cardíacos, intoxicación por opioides, malaria, enfermedades pediátricas transmisibles y desnutrición. Entre los alumnos se encontraban el público en general, los profesionales no sanitarios, los voluntarios y los contactos cercanos de las poblaciones de riesgo, todos ellos formados a través de campañas de educación y concienciación pública presenciales, entre compañeros y multimodales. Los resultados clínicos y políticos más importantes fueron la mejora de la capacidad de la comunidad para gestionar emergencias (14 estudios), los resultados de los pacientes (13 estudios) y la salud de la comunidad (7 estudios). Aunque se observaron efectos sustanciales en los programas para abordar la malaria pediátrica, los traumatismos y la intoxicación por opioides, la mayoría de los estudios informaron de tamaños de efecto modestos y dos informaron de resultados nulos. La mayoría de los estudios fueron de calidad débil (24 estudios) o moderada (9 estudios).La formación de personas en primeros auxilios y la transferencia de tareas a los legos para la atención de emergencias pueden reducir la morbilidad y la mortalidad de los pacientes y fomentar la capacidad de la comunidad para gestionar las emergencias sanitarias en una variedad de condiciones de emergencia en entornos desatendidos y de bajos recursos.الغرض تقييم الآثار الصحية الفردية والمجتمعية لتحويل المهام للرعاية الطارئة في البيئات منخفضة الموارد، والفئات السكانية المحرومة حول العالم. الطريقة قمنا بالبحث بشكل منهجي في 13 قاعدة بيانات ومؤلفات رمادية غير رسمية للدراسات المنشورة ما بين عامي 1984 و2019. تضمنت الدراسات الملائمة تدريبًا على رعاية الطوارئ للأشخاص العاديين في المجموعات السكانية المحرومة أو منخفضة الموارد، وأي تقييم كمي للتأثيرات على صحة الأفراد أو المجتمعات. وأجرينا تقييمات مزدوجة لمدى ملاءمة الدراسة، واستخراج البيانات والجودة. وقمنا بتجميع النتائج في صيغة سردية وشكل جداول. النتائج من بين 19308 ورقة بحثية تم استرجاعها، استوفت 34 دراسة معايير الاشتمال من الدول منخفضة ومتوسطة الدخل (21 دراسة)، والفئات السكانية المحرومة من الخدمات في الدول مرتفعة الدخل (13 دراسة). وشملت حالات الطوارئ المستهدفة الصدمات، والحروق، والسكتة القلبية، والتسمم بالمواد الأفيونية، والملاريا، والأمراض المعدية للأطفال، وسوء التغذية. وكان من بين المتدربين عامة الناس، وأخصائيو الرعاية الصحية، والمتطوعون، وجهات الاتصال المقربة من السكان المعرضين للخطر، وجميعهم مدربون من خلال حملات التوعية العامة والتثقيف داخل الفصول، وعبر الأقران، والوسائط المتعددة. تضمنت النتائج الهامة سواء الإكلينيكية والمتعلقة بالسياسة تحسينات في قدرة المجتمع على إدارة حالات الطوارئ (14 دراسة)، ونتائج المرضى (13 دراسة)، والصحة المجتمعية (7 دراسات). بينما لوحظت تأثيرات ملموسة لبرامج معالجة الملاريا عند الأطفال، والصدمات، والتسمم بالمواد الأفيونية، إلا أن معظم الدراسات أوضحت أحجام تأثير متواضعة، وأشارت دراستان إلى نتائج غير موثوقة. كانت معظم الدراسات ذات جودة ضعيفة (24 دراسة)، أو جودة متوسطة (تسع دراسات). الاستنتاج إن تعليم الإسعافات الأولية، وتحويل المهام إلى الأشخاص العاديين للرعاية الطارئة، قد يؤدي إلى تقليل معدلات الإصابة بالأمراض ووفيات المرضى، وبناء قدرة المجتمع على إدارة حالات الطوارئ الصحية لمجموعة متنوعة من حالات الطوارئ في البيئات المحرومة من الخدمات وقليلة الموارد.旨在评估在世界范围内医疗资源匮乏和服务不足的人群中,紧急护理任务转移对个人和社区健康的影响。.我们系统地检索了 13 个数据库和额外的灰色文献,以查找 1984 年至 2019 年之间发表的研究。符合条件的研究包括在医疗资源匮乏或服务不足的人群中对非专业人员开展的紧急护理培训,以及对个人或社区健康影响的任何定量评估。我们对研究的资格、数据提取和质量进行了重复评估。我们以叙述和表格的形式汇总了研究结果。.在检索到的 19,308 篇论文中,其中 34 项研究符合中低收入国家(21 项研究)和高收入国家医疗资源匮乏人群(13 项研究)的纳入标准。研究针对的紧急情况包括创伤、烧伤、心脏骤停、类阿片中毒、疟疾、儿科传染病和营养不良。接受培训的人员包括普通群众、非医疗专业人员、志愿者和高危人群的密切接触者,所有这些人员都通过课堂教育、同伴互助教育和多模式教育以及公益宣传活动接受了培训。重要的临床和政策结果包括改善社区应对紧急情况的能力(14 项研究)、患者结果(13 项研究)和社区健康(7 项研究)。虽然观察到针对儿科疟疾、创伤和阿片类药物中毒的项目产生了重大影响,但大多数研究报告的效果并不大,而且有两项报告没有结果。大多数研究的质量较差(24 项研究)或一般(9 项研究)。.急救教育和将紧急护理任务移交给非专业人员可以降低患者的发病率和死亡率,并培养社区在医疗资源匮乏和服务不足的环境中应对各种紧急情况的能力。.Оценить влияние передачи задач по оказанию неотложной помощи в условиях ограниченных ресурсов и недостаточного обслуживания населения на здоровье отдельных лиц и общин во всем мире.Авторы провели систематический поиск в 13 базах данных и дополнительно по неиндексированной в базах данных литературе на предмет исследований, опубликованных в период с 1984 по 2019 год. Соответствующие критериям исследования включали обучение неотложной помощи для неспециалистов из групп населения с недостаточным уровнем обслуживания или ресурсов, а также любую количественную оценку воздействия на здоровье отдельных лиц или общин. Проведена двойная оценка пригодности к участию в исследовании, абстракции данных и качества. Результаты обобщены в повествовательной и табличной форме.Из 19 308 отобранных статей 34 исследования соответствовали критериям включения из стран с низким и средним уровнем доходов (21 исследование) и групп населения с недостаточным уровнем обслуживания в странах с высоким уровнем доходов (13 исследований). К числу целевых чрезвычайных ситуаций относятся: травмы, ожоги, остановка сердца, отравление опиоидами, малярия, детские инфекционные заболевания и недоедание. В число стажеров входили представители широкой общественности, специалисты, не занимающиеся вопросами здравоохранения, добровольцы и лица, поддерживающие тесные контакты с населением, входящим в группу риска. Все они прошли обучение в рамках аудиторных, коллегиальных и смешанных образовательных и информационно-просветительских кампаний. К числу важных результатов клинической и политической деятельности относятся: улучшение потенциала общин в области управления чрезвычайными ситуациями (14 исследований), результаты лечения пациентов (13 исследований) и охрана здоровья общин (7 исследований). Хотя в программах по борьбе с детской малярией, травмами и отравлениями опиоидами наблюдались существенные изменения, в большинстве исследований сообщалось о незначительной эффективности, а в двух исследованиях сообщалось о нулевых результатах. Большинство исследований показали низкую (24 исследования) или умеренную (9 исследований) степень эффективности.Просвещение по вопросам оказания первой медицинской помощи и передача функций по оказанию неотложной помощи неспециалистам могут снизить заболеваемость и смертность пациентов и укрепить потенциал общин по управлению чрезвычайными ситуациями в области здравоохранения в различных чрезвычайных ситуациях в условиях недостаточного обслуживания и нехватки ресурсов.

Portable ultrasound is a burgeoning technology with unrealized potential at a critical point in its evolution [1]. Francis Galton first generated ultrasound waves in 1876; however, it wasn’t until 1940 that ultrasound was first applied to clinical medicine [2]. Reaching a “tipping point”, ultrasound is being rapidly assimilated into many medical specialties beyond radiology, now in the hands of non-radiologist, non-cardiologist novel users [2].

Objective Community paramedicine (CP) is a model of community-based health care being used around the world. Our objective was to study the patient perspective and valuation of this type of program to understand its potential value for primary care innovation in the future. Study setting The EPIC community paramedicine program is a partnership between primary care physicians and specially trained community paramedics, designed to provide in-home support for complex chronic disease patients in Ontario, Canada. Study design As part of an ongoing clinical trial we designed an embedded qualitative evaluation using constructionist grounded theory methodology. Data collection methods Data collection included in-depth interviews with 30 patients and/or family members and 60 hours of observation. Principal findings The health care needs of this complex population are largely attributes that impact a patient's quality of life-including recognition of their vulnerability, providing a safety-net in times of exacerbation and health education and accountability. This seems to be facilitated by a relationship with a dedicated provider that increases continuity of care. Conclusions Home-based community paramedicine programs like EPIC appear to be able to create a patient-centered, safe, responsive therapeutic relationship that is often not possible within the standard primary health care system.

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.

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.

Introduction: Time-to-treatment plays a pivotal role in survival from sudden cardiac arrest (SCA). Every minute delay in defibrillation results in a 7-10% reduction in survival. This is particularly problematic in rural and remote regions, where bystander and EMS response is often prolonged and automated external defibrillators (AED) are often not available. Our objective was to examine the feasibility of a novel AED drone delivery method for rural and remote SCA. A secondary objective was to compare times between AED drone delivery and ambulance response to various mock SCA resuscitations. Methods: We conducted 6 simulations in two different rural communities in southern Ontario. During phase 1 (4 simulations) a “mock” call was placed to 911 and a single AED drone and an ambulance were simultaneously dispatched from the same location to a pre-determined destination. Once on scene, trained first responders retrieved the AED from the drone and initiated resuscitative efforts on a manikin. The second phase (2 scenarios) were done in a similar manner save for the drone being dispatched from a regionally optimized location for drone response. Results: Phase 1: The distance from dispatch location to scene varied from 6.6 km to 8.8 km. Mean (SD) response time from 911 call to scene arrival was 11.2 (+/- 1.0) minutes for EMS compared to 8.1 (+/- 0.1) for AED drone delivery. In all four simulations, the AED drone arrived before EMS, ranging from 2.1 to 4.4 minutes faster. The mean time for trained responders to retrieve the AED and apply it to the manikin was 35 (+/- 5) sec. No difficulties were encountered in drone activation by dispatch, drone lift off, landing or removal of the AED from the drone by responders. Phase 2: The ambulance response distance was 20km compared to 9km for the drone. Drones were faster to arrival at the scene by 7 minutes and 8 minutes with AED application 6 and 7 minutes prior to ambulance respectively. Conclusion: This implementation study suggests AED drone delivery is feasible with improvements in response time during a simulated SCA scenario. These results suggest the potential for AED drone delivery to decrease time to first defibrillation in rural and remote communities. Further research is required to determine the appropriate distance for drone delivery of an AED in an integrated EMS system as well as optimal strategies to simplify bystander application of a drone delivered AED.

Background: Despite significant advances in resuscitation efforts, there are some patients who remain in ventricular fibrillation (VF) after multiple defibrillation attempts during out-of-hospital cardiac arrest (OHCA). Double sequential external defibrillation (DSED) and vector change defibrillation (VC) have been proposed as alternate therapeutic strategies for OHCA patients in shock-refractory VF. Objective: To determine the feasibility, safety and sample size required for a larger, multicentered, 3-arm, cluster randomized controlled trial (RCT) with 2 crossovers comparing DSED or VC to standard defibrillation (control group) for OHCA patients presenting in shock-refractory VF. Methods: We conducted a pilot cluster randomized controlled trial with crossover including all consecutive treated adult OHCA patients who presented in VF and received a minimum of three successive shocks. In addition to standard cardiac arrest care, each EMS agency was randomly assigned to provide standard defibrillation (control), DSED, or VC, followed by crossover to an alternate defibrillation strategy after 6 months. Results: Prior to the launch of the trial, 2,500 paramedics received in-person training in the techniques of DSED and VC defibrillation using a combination of didactic, video and simulated scenarios. Between March 2018 and June 2019, 113 patients were enrolled in 4 Canadian EMS agencies, with zero missed cases. Monthly enrollment varied from 1 to 6 cases per agency. With respect to feasibility, 96% of cases were compliant with the study protocol, and only five (4.4%) cases received a defibrillation strategy that differed from the allocation schedule. There were no reported cases of defibrillator malfunction, no concerns expressed by paramedics, patients, families, or ED staff about the trial, and no reported cases of skin burns or difficulty with pad placement. Conclusions: Findings from our pilot implementation trial suggest the DOSE VF protocol is feasible and safe. The results of this internal pilot trial will allow us to calculate a sample size for a definitive multicenter cluster RCT with crossovers to determine if these alternate defibrillation strategies for OHCA shock refractory VF will impact patient-centered, clinical outcomes.

The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the third annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. It addresses the most recent published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. This summary addresses the role of cardiac arrest centers and dispatcher-assisted cardiopulmonary resuscitation, the role of extracorporeal cardiopulmonary resuscitation in adults and children, vasopressors in adults, advanced airway interventions in adults and children, targeted temperature management in children after cardiac arrest, initial oxygen concentration during resuscitation of newborns, and interventions for presyncope by first aid providers. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the certainty of the evidence on the basis of the Grading of Recommendations, Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence to Decision Framework Highlights sections. The task forces also listed priority knowledge gaps for further research.

The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the third annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. It addresses the most recent published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. This summary addresses the role of cardiac arrest centers and dispatcher-assisted cardiopulmonary resuscitation, the role of extracorporeal cardiopulmonary resuscitation in adults and children, vasopressors in adults, advanced airway interventions in adults and children, targeted temperature management in children after cardiac arrest, initial oxygen concentration during resuscitation of newborns, and interventions for presyncope by first aid providers. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the certainty of the evidence on the basis of the Grading of Recommendations, Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence to Decision Framework Highlights sections. The task forces also listed priority knowledge gaps for further research.

Background Cardiopulmonary resuscitation (CPR) process measures research and quality assurance has traditionally been limited to the first 5 minutes of resuscitation due to significant costs in time, resources, and personnel from manual data abstraction. CPR performance may change over time during prolonged resuscitations, which represents a significant knowledge gap. Moreover, currently available commercial software output of CPR process measures are difficult to analyze. Objective The objective was to develop and validate a software program to help automate the abstraction and transfer of CPR process measures data from electronic defibrillators for complete episodes of cardiac arrest resuscitation. Methods We developed a software program to facilitate and help automate CPR data abstraction and transfer from electronic defibrillators for entire resuscitation episodes. Using an intermediary Extensible Markup Language export file, the automated software transfers CPR process measures data (electrocardiogram [ECG] number, CPR start time, number of ventilations, number of chest compressions, compression rate per minute, compression depth per minute, compression fraction, and end-tidal CO2 per minute). We performed an internal validation of the software program on 50 randomly selected cardiac arrest cases with resuscitation durations between 15 and 60 minutes. CPR process measures were manually abstracted and transferred independently by two trained data abstractors and by the automated software program, followed by manual interpretation of raw ECG tracings, treatment interventions, and patient events. Error rates and the time needed for data abstraction, transfer, and interpretation were measured for both manual and automated methods, compared to an additional independent reviewer. Results A total of 9,826 data points were each abstracted by the two abstractors and by the software program. Manual data abstraction resulted in a total of six errors (0.06%) compared to zero errors by the software program. The mean ± SD time measured per case for manual data abstraction was 20.3 ± 2.7 minutes compared to 5.3 ± 1.4 minutes using the software program (p = 0.003). Conclusions We developed and validated an automated software program that efficiently abstracts and transfers CPR process measures data from electronic defibrillators for complete cardiac arrest episodes. This software will enable future cardiac arrest studies and quality assurance programs to evaluate the impact of CPR process measures during prolonged resuscitations.

Managing out-of-hospital cardiac arrest requires paramedics to perform multiple aerosol generating medical procedures in an uncontrolled setting. This increases the risk of cross infection during the COVID-19 pandemic. Modifications to conventional protocols are required to balance paramedic safety with optimal patient care and potential stresses on the capacity of critical care resources. Despite this, little specific advice has been published to guide paramedic practice. In this commentary, we highlight challenges and controversies regarding critical decision making around initiation of resuscitation, airway management, mechanical chest compression, and termination of resuscitation. We also discuss suggested triggers for implementation and revocation of recommended protocol changes and present an accompanying paramedic-specific algorithm.

Introduction: Despite recent advances in resuscitation, some patients remain in ventricular fibrillation (VF) after multiple defibrillation attempts during out-of-hospital cardiac arrest (OHCA). Vector change defibrillation (VC) and double sequential external defibrillation (DSED) have been proposed as alternate therapeutic strategies for OHCA patients with refractory VF. The primary objective was to determine the feasibility, safety and sample size required for a future cluster randomized controlled trial (RCT) with crossover comparing VC or DSED to standard defibrillation for patients experiencing refractory VF. Secondary objectives were to evaluate the intervention effect on VF termination and return of spontaneous circulation (ROSC). Methods: We conducted a pilot cluster RCT with crossover in four Canadian paramedic services and included all treated adult OHCA patients who presented in VF and received a minimum of three defibrillation attempts. In addition to standard cardiac arrest care, each EMS service was randomly assigned to provide continued standard defibrillation (control), VC or DSED. Services crossed over to an alternate defibrillation strategy after six months. Prior to the launch of the trial, 2,500 paramedics received in-person training for VC and DSED defibrillation using a combination of didactic, video and simulated scenarios. Results: Between March 2018 and September 2019, 152 patients were enrolled. Monthly enrollment varied from 1.4 to 6.1 cases per service. 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 reported cases of defibrillator malfunction, skin burns, difficulty with pad placement or concerns expressed by paramedics, patients, families, or ED staff about the trial. In the standard defibrillation group, 66.6% of cases resulted in VF termination, compared to 82.0% in VC and 76.3% of cases in the DSED group. ROSC was achieved in 25.0%, 39.3% and 40.0% of standard, VC and DSED groups, respectively. Conclusion: Findings from our pilot RCT suggest the DOSE VF protocol is feasible and safe. VF termination and ROSC were higher with VC and DSED compared to 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 patient-centered, clinical outcomes

Introduction: Community paramedic programs are being implemented to leverage existing resources and contribute to a sustainable patient-centered healthcare system. Expanding the role of paramedics into home care requires new collaborative relationships with healthcare providers such as nurses and physicians. Developing effective and productive collaborative relationships will enhance and support the integration of community paramedic programs. Our objective was to describe the barriers and facilitators to effective collaboration between nurses, physicians, and paramedics within home-based community paramedicine. Methods: We conducted semi-structured interviews with nurses, physicians, paramedics, and faculty who teach in paramedic programs. We explored the attitudes, perceptions, barriers, and enablers to collaboration in home-based community paramedic programs. Participants were recruited utilizing the professional networks of the researchers as well as snowball sampling. Recruitment in each group stopped when saturation was achieved. We conducted a thematic analysis of the interviews to generate findings related to our objectives. Results: We interviewed 33 participants with a typical cross-section of age, years of experience, and education. Overall, participants felt that collaboration was important for effective integration of community paramedics into home care and for ensuring a patient-centered approach to care. Currently, collaboration mostly occurs between physicians and paramedics and community paramedicine appears to be a siloed rather than integrated service. Few collaborative relationships exist between paramedics and nurses, despite the fact that nurses are highly involved in home care. We identified several barriers to effective collaboration including lack of understanding of the contributions of the different health providers, and regulatory and funding constraints. Inter-professional education that supports collaboration and facilitates dismantling of professional and service silos can support the effective integration of paramedics into home care. Conclusion: Strengthening networks of collaboration between nurses, physicians, and paramedics can help dismantle silos and enhance inter-professional collaboration to support appropriate integration of paramedics into home care. The willingness and positive attitudes for collaboration are assets that provide an excellent foundation upon which to move forward. Continuing education to support inter-professional collaboration is needed.

Background Considerable effort has gone into improving outcomes from out-of-hospital cardiac arrest (OHCA). Studies suggest that survival is improving; however, prior studies had insufficient data to pursue the relationship between markers of guideline compliance and temporal trends. The objective of the study was to evaluate trends in OHCA survival over an 8-year period that included the implementation of the 2005 and 2010 international cardiopulmonary resuscitation (CPR) guidelines. Methods and Results This was a population-based cohort study of all consecutive treated OHCA patients of presumed cardiac cause between 2006 and 2013 in the City of Toronto, Canada, and surrounding regions. Temporal changes were measured by χ 2 trend test. The association between year of the OHCA and survival was evaluated using logistic regression and joinpoint analysis. A total of 23 619 patients with OHCA met study inclusion criteria. During the study period, survival to hospital discharge doubled (4.8% in 2006 to 9.4% in 2013; P P =0.005). Improvements occurred in the rates of bystander CPR and automated external defibrillator application, high-quality CPR metrics, and in-hospital targeted temperature management. After adjusting for the Utstein variables, survival to hospital discharge (odds ratio, 1.12; 95% confidence interval, 1.09–1.15) and survival with good neurological outcome (odds ratio, 1.13; 95% confidence interval, 1.05–1.22) increased with each year of study. Conclusions Survival after OHCA has improved over time. This trend was associated with improved rates of bystander CPR, automated external defibrillator use, high-quality CPR metrics, and in-hospital targeted temperature management. The results suggest that multiple factors, each improving over time, may have contributed to the observed increase in survival.

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.

Objectives: Emergency departments (ED) continue to be overburdened, leading to crowding and elevated risk of negative clinical outcomes. Extending clinical services to paramedics may support efforts to improve ED burdens by promoting health care access and capacity during times of patient crisis. The objective of this study was to identify the clinical course and most responsible diagnosis of patients transported by paramedic services to local EDs to then evaluate impact of various augmented 9-1-1/paramedic clinical service models on the need for additional ED services. Methods: A retrospective cohort and model-simulation based study. We retrieved clinical data from hospital records for a random selection of 3,000 patients who engaged 9-1-1/paramedic services and were transported to a regional ED to identify their clinical course (interventions, diagnostics) disposition and most responsible admitting/discharge diagnosis. We used this data to establish, simulate and test numerous paramedic service models on the need for ED services. Results: A random selection of 3,000 patients was reviewed across 3 hospitals. The majority were female (57.2%) with a mean age of 65 (SD = 21.3). The majority (n = 1954; 65.1%) were discharged directly from ED of which 3.6% (n = 108) received no intervention or diagnostic, 20.4% (n = 611) received only a diagnostic, 4.8% (n = 143) received only an intervention and 36.4% (n = 1092) received both an intervention and diagnostic. The proportion of nonadmitted patients rose to 82.2% and 77.2% when considering lower priority patients and age greater than 65, respectively. Patient types were identified based on frequency and association with discharge directly from ED. Twelve simulated augmented paramedic clinical service models are reported with estimated gains in the number of patients who may no longer require ED services ranging from 7.5% (n = 146) to 35.4% (n = 691). Conclusions: This study suggests a reduction in need for ED services may be achieved through innovative models of paramedic services at the time of crisis. Identifying and confirming patient types/events to target and clinical services to include in the model requires ongoing investigation. Future research will be needed to evaluate the accuracy and impact of the models presented. Keywords: Paramedic; EMS; Community Paramedicine; Healthcare Service Delivery; ED Crowding; primary care

Background Drug overdose causes approximately 183,000 deaths worldwide annually and 50,000 deaths in Canada and the United States combined. Drug-related deaths are concentrated among young people, leading to a substantial burden of disease and loss of potential life years. Understanding the epidemiology, patterns of care, and prognosis of drug-related prehospital emergencies may lead to improved outcomes. Methods We conducted a retrospective cohort study of out-of-hospital cardiac arrests with drug-related and presumed cardiac causes between 2007 and 2013 using the Toronto Regional RescuNet Epistry database. The primary outcome was survival to hospital discharge. We computed standardized case fatality rates, and odds ratios of survival to hospital discharge for cardiac arrests with drug-related versus presumed cardiac causes, adjusting for confounders using logistic regression. Results The analysis involved 21,497 cardiac arrests, including 378 (1.8%) drug-related and 21,119 (98.2%) presumed cardiac. Compared with the presumed cardiac group, drug-related arrest patients were younger and less likely to receive bystander resuscitation, have initial shockable cardiac rhythms, or be transported to hospital. There were no significant differences in emergency medical service response times, return of spontaneous circulation, or survival to discharge. Standardized case fatality rates confirmed that these effects were not due to age or sex differences. Adjusting for known predictors of survival, drug-related cardiac arrest was associated with increased odds of survival to hospital discharge (OR1.44, 95%CI 1.15–1.81). Interpretation In out-of-hospital cardiac arrest, patients with drug-related causes are less likely than those with presumed cardiac causes to receive bystander resuscitation or have an initial shockable rhythm, but are more likely to survive after accounting for predictors of survival. The demographics and outcomes among drug-related cardiac arrest patients offers unique opportunities for prehospital intervention.

Introduction: Pediatric out-of-hospital cardiac arrest (OHCA) is unique in terms of epidemiology, treatment, and outcomes. There is a paucity of literature examining predictors of survival to help guide resuscitation in this population. Objective: The primary objective was to examine predictors of survival to hospital discharge. The secondary objective was to determine the probability of return of spontaneous circulation (ROSC) over the duration of resuscitation. Methods: We performed a retrospective cohort study of non-traumatic OHCA (Results: A total of 658 patients met inclusion criteria. Survival to discharge was 10.2% with 70.1% of those children having a good neurologic outcome. The overall median time to ROSC was 23.9 min. (IQR 15.0,36.7). However, the median time to ROSC for survivors was significantly shorter than the time to ROSC for patients who died in hospital (15.9 (IQR 10.6 to 22.8) vs. 33.2 (IQR 22.0 to 48.6); P value Conclusion: Inclusion of duration of resuscitation improved the performance of our model compared to Utstein factors alone. However, our results suggest there are a number of other important factors for predicting patient outcome from pediatric OHCA.

Background: The increasing number of people living in high-rise buildings presents unique challenges to care and may cause delays for 911-initiated first responders (including paramedics and fire department personnel) responding to calls for out-of-hospital cardiac arrest. We examined the relation between floor of patient contact and survival after cardiac arrest in residential buildings. Methods: We conducted a retrospective observational study using data from the Toronto Regional RescuNet Epistry database for the period January 2007 to December 2012. We included all adult patients (≥ 18 yr) with out-of-hospital cardiac arrest of no obvious cause who were treated in private residences. We excluded cardiac arrests witnessed by 911-initiated first responders and those with an obvious cause. We used multivariable logistic regression to determine the effect on survival of the floor of patient contact, with adjustment for standard Utstein variables. Results: During the study period, 7842 cases of out-of-hospital cardiac arrest met the inclusion criteria, of which 5998 (76.5%) occurred below the third floor and 1844 (23.5%) occurred on the third floor or higher. Survival was greater on the lower floors (4.2% v. 2.6%, p = 0.002). Lower adjusted survival to hospital discharge was independently associated with higher floor of patient contact, older age, male sex and longer 911 response time. In an analysis by floor, survival was 0.9% above floor 16 (i.e., below the 1% threshold for futility), and there were no survivors above the 25th floor. Interpretation: In high-rise buildings, the survival rate after out-of-hospital cardiac arrest was lower for patients residing on higher floors. Interventions aimed at shortening response times to treatment of cardiac arrest in high-rise buildings may increase survival.

Introduction: Targeted temperature management (TTM) reduces neurologic injury from out-of-hospital cardiac arrest (OHCA). As the risk of neurologic injury increases with prolonged cardiac arrests, the benefit of TTM may depend upon cardiac arrest duration. We hypothesized that there is a time-dependent effect of TTM on neurologic outcomes from OHCA. Methods: Retrospective, observational study of the Toronto RescuNET Epistry-Cardiac Arrest database from 2007 to 2014. We included adult (>18) OHCA of presumed cardiac etiology that remained comatose (GCS Results: There were 1496 patients who met our inclusion criteria, of whom 981 (66%) received TTM. Of the patients who received TTM, 59% had a good neurologic outcome compared to 39% of patients who did not receive TTM (p< 0.001). After adjusting for the Utstein variables, use of TTM was associated with improved neurologic outcome (OR 1.60, 95% CI 1.10-2.32; p = 0.01) but not with survival to discharge (OR 1.23, 95% CI 0.90-1.67; p = 0.19). The impact of TTM on neurologic outcome was dependent on the duration of cardiac arrest (p Conclusion: The use of TTM was associated with improved neurologic outcome at hospital discharge. Patients with prolonged durations of cardiac arrest benefited more from TTM.

Introduction: Research and quality assessment of cardiopulmonary resuscitation (CPR) quality has traditionally been limited to the first five minutes of resuscitation due to significant costs in both time and personnel from manual data abstraction. Manual CPR quality data abstraction of entire episodes of resuscitation may be too resource-intensive for many emergency medical service (EMS) agencies and hospitals. Moreover, the first five minutes of CPR are also different in many aspects compared to later time periods during cardiac arrest resuscitation, which represents significant knowledge gaps since the majority of resuscitations go beyond five minutes. Methods: We developed a software program to facilitate and help automate data abstraction from electronic defibrillator files for entire resuscitation episodes. Internal validation of the software program was performed on 50 randomly selected out-of-hospital cardiac arrest cases with resuscitation durations up to 60 minutes. CPR quality data variables were abstracted as minute averages, which included ventilation rate, CPR compression rate, depth, fraction, and end-tidal CO2. CPR quality data variables were manually abstracted independently by two trained data abstractors and automatically by the software program. Error rates and the time needed for data abstraction were measured. Results: A total of 9826 data points were abstracted. Manual data abstraction resulted in a total of six errors (0.06%) compared to zero errors by the software program. The mean time ± SD needed for data abstraction was 20.3 ± 2.7 minutes manually and 5.3 ± 1.4 minutes using the software program (p=0.003). Conclusion: Our data abstraction software was 100% accurate in abstracting CPR quality data for complete cardiac arrest resuscitation episodes. It significantly reduced the time and resources required to abstract CPR quality data, and will allow EMS agencies and hospitals to evaluate their CPR quality in a cost-effective manner. The development of this software will enable future studies to efficiently evaluate CPR quality during entire resuscitation episodes, including its impact on patient outcomes during prolonged cardiac arrests.

This Part of the 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) addresses cardiac arrest in situations that require special treatments or procedures other than those provided during basic life support (BLS) and advanced cardiovascular life support (ACLS). This Part summarizes recommendations for the management of resuscitation in several critical situations, including cardiac arrest associated with pregnancy (Part 10.1), pulmonary embolism (PE) (10.2), and opioid-associated resuscitative emergencies, with or without cardiac arrest (10.3). Part 10.4 provides recommendations on intravenous lipid emulsion (ILE) therapy, an emerging therapy for cardiac arrest due to drug intoxication. Finally, updated guidance for the management of cardiac arrest during percutaneous coronary intervention (PCI) is presented in Part 10.5. A table of all recommendations made in this 2015 Guidelines Update as well as those made in the 2010 Guidelines is contained in the Appendix. The special situations of resuscitation section (Part 12) of the 2010 AHA Guidelines for CPR and ECC 1 covered 15 distinct topic areas. The following topics were last updated in 2010: Additional information about drowning is presented in Part 5 of this publication, “Adult Basic Life Support and Cardiopulmonary Resuscitation Quality.” The recommendations in this 2015 Guidelines Update are based on an extensive evidence review process that was begun by the International Liaison Committee on Resuscitation (ILCOR) with the publication of the ILCOR 2010 International Consensus on CPR and ECC Science With Treatment …

Objective To identify studies describing the accuracy of prehospital sepsis identification and to summarise results of studies of prehospital management of patients with sepsis, severe sepsis or septic shock. Methods We conducted a systematic review to retrieve studies that evaluated the prehospital identification or treatment of patients with sepsis by emergency medical services (EMS). Two authors extracted data describing the study characteristics, incidence of sepsis among EMS-transported patients, criteria used to identify sepsis and specific treatments provided to patients with sepsis. When possible, we calculated the sensitivity and specificity of EMS provider diagnosis of sepsis. Results Our search identified no randomised controlled trials and 16 cohort studies. Eight studies described the identification of sepsis, seven described prehospital management or treatment of sepsis and one described both. The most common approach to the identification of sepsis involved applying systemic inflammatory response syndrome criteria or a combination of vital signs, which had sensitivity ranging from 0.43 to 0.86 when used alone or combined with provider impression. Only four studies collected information required to calculate specificity (0.47–0.87). Meta-analysis was not performed owing to significant heterogeneity and an overall low quality of evidence. A few studies described prehospital sepsis treatment—most commonly intravenous fluid resuscitation. Conclusions The evidence suggests that identification of sepsis in the prehospital setting by EMS providers is carried out with varied success, depending on the strategy used; however, high-quality studies are lacking. Relying on provider impression alone had poor sensitivity, but some moderate-quality evidence supporting structured screening for sepsis with vital signs criteria demonstrated modest sensitivity and specificity. Additional research to improve diagnostic accuracy and explore improvements in EMS management is needed.