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Introduction: We sought to assess the effect of in-hospital targeted temperature management (TTM) on outcomes of non-shockable out-of-hospital cardiac arrest (OHCA). Methods: This is a secondary analysis of a randomized controlled trial “A Randomized Trial of Continuous Versus Interrupted Chest Compressions in Out-of-Hospital Cardiac Arrest” (NCT01372748). We included non-traumatic comatose OHCAs with non-shockable rhythm who survived to hospital admission. Outcomes of interest were survival at hospital discharge and favorable neurological outcome (modified Rankin scale 0-3). We performed multivariable logistic regression, adjusting for baseline characteristics to determine the association between TTM and outcomes, compared to no TTM, for the entire cohort as well as for the propensity matched cohort. Results: Of 1,985 OHCAs who survived to hospital admission, 780 (39.3%) were managed with TTM. In TTM patients, 7.3 % patients survived to hospital discharge and 3.9 % had a favorable neurological outcome in contrast to 10.2 % and 6.1 %, respectively, in no TTM patients. Multivariable analyses demonstrated an association between TTM and decreased probability of both outcomes, compared to no TTM (adjusted ORs for survival: 0.67 95% CI 0.48–0.93, and for favorable neurological outcome: 0.57 95% CI 0.37–0.90). Propensity score matched analyses demonstrate the similar results. Conclusion: TTM might decrease the probability of neurologically intact survival for non-shockable OHCAs.

Introduction: ST-elevation myocardial infarction (STEMI) presenting to the ED is a significant health burden. The provision of IV morphine with doses titrated to provide comfort is recommended in the AHA STEMI Guidelines, yet there is limited evidence of safety in this setting. The primary objective of this study was to measure potential harm associated with the provision of IV morphine in STEMI patients presenting to the ED. Methods: This was a two centre retrospective chart review from an urban, inner city, academic ED with an annual census of 85,000 visits, and an affiliated community hospital with 35,000 annual visits. Consecutive patients from April 2009 to January 2015 presenting to the 2 EDs with a diagnosis of STEMI were identified in the ED database. Eight trained research assistants, blinded to the study hypothesis, used standardized data collection templates. The primary investigator double collected 20% of all data to ensure completeness and accuracy. Results: We included 311 patients with STEMI (124 received morphine [M]; 187 no morphine [nM]). The ages of the two groups were similar (mean 64 yrs [M] & 67 yrs [nM]; median 63 yrs [M] & 66 yrs [nM]; IQR 45-81 [M] and 45.5-86.5 [nM]); as were the proportion of female patients (21.0% [M] & 23.5% [nM]. The pre-STEMI Charlson comorbidity scores (mean 2.6), median time to first ECG (11 min [M] & 16 min [nM]), and mean time-to-needle for PCI (96.8 min [M] & 92.0 min [nM]) were similar between groups. The mean CCU length of stay (LOS) (9.3 days vs 6.3 days) and hospital LOS (7.4 days vs 4.6 days) were longer for patients receiving morphine than those not receiving morphine. Rates of congestive heart failure, acute kidney injury and cardiac arrest in hospital were unchanged between the groups. Unadjusted mortality was similar (10.5% [M] vs 13.3% [nM]) between groups. Binary logistic regression controlling for age, Charlson score, first and peak troponin values demonstrated an association between receiving morphine in the ED and an increased risk of death at 30 days (OR 8.1; 95% CI 7.1.-9.1). Conclusion: The provision of morphine to patients with STEMI in the ED may be associated with increased CCU and hospital LOS. When controlling for age, pre-STEMI Charlson score, first and peak troponin values, receiving morphine was associated with an increased risk of death at 30 days. Further research to elucidate this association is warranted.

Introduction: Amiodarone may be used for shock-refractory ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT), but the effect of prehospital use upon neurological outcomes still unclear. Methods: A prospective province-wide, population based observational study was conducted from January 2006 to March 2016. Adult emergency medical service-treated non-traumatic OHCA patients who received at least one electric defibrillation were included. Amiodarone was administered to patients with VF/ pVT by paramedics based on their clinical assessment, according to provincial guidelines. The outcome of interest was favorable neurological outcomes to hospital discharge, defined as modified Rankin scale of 3 or less. Multivariable logistic regression was performed to compare the proportion of patients with the primary outcome between amiodarone and non-amiodarone groups, further stratified by the number of electrical defibrillation. In addition, to mitigate the potential selection bias, the same logistic regression was conducted in 1:1 propensity score matched groups adjusting for baseline covariates. Results: Of 3,374 overall OHCA patients, 915 (27.1%) were managed with amiodarone. In the amiodarone group, 150 / 915 (16.4 %) patients had a favorable neurological outcome, compared to 455/2,459 (18.5%) in the non-amiodarone group (crude odds ratio [OR] 0.86, 95% CI 0.71 to 1.06). In the multiple logistic regression model, prehospital amiodarone was associated with increased probability of favorable neurological outcomes (adjusted OR 2.11, 95% CI 1.46 to 3.05). With stratification by the number of electrical defibrillation performed, amiodarone treated group showed higher probability of favorable neurological outcomes (1 or 2: adjusted OR 2.71, 95% CI 1.33 to 5.50, 3 and more: adjusted OR 1.67, 95% CI 0.99 to 2.39). Similarly, in 1:1 propensity matched cohort including 882 OHCA patients, the adjusted association persisted (adjusted OR 2.14, 95% CI 1.33 to 3.44). Conclusion: Prehospital administration of amiodarone to non-traumatic OHCA patients was associated with better neurological recovery, especially in those who received fewer electrical defibrillations.

Introduction: Survival for victims of out-of-hospital cardiac arrest (OHCA) is typically between 8 and 12%. We sought to report the trends in survival in British Columbia (BC) over a 10-year period. Methods: The BC Resuscitation Outcomes Consortium prospectively collected detailed prehospital and hospital data on consecutive non-traumatic OHCAs from 2006 to 2016 within BC’s four metropolitan areas. We included EMS-treated adult patients without DNR orders. To describe baseline characteristics we organized patient characteristics in three time periods: 2006-09, 2010-13, and 2014-16 (first and last periods reported below). The primary and secondary endpoints were survival at hospital discharge and return of spontaneous circulation (ROSC). We tested the significance of year-by-year trends in baseline characteristics, and performed multivariable Poisson regression, using calendar year as an independent variable, to calculate risk-adjusted rates for survival. Results: Between January 1, 2006 and March 31, 2016 there were a total of 26 433 non-traumatic OHCAs, with 15 145 included in this study. There were significant decreases in the proportion with initial shockable cardiac rhythms (28% to 23%) and bystander witnessed arrests (42% to 39%), however significant increases in the proportion with bystander CPR (40% to 49%) and ALS treatment (86% to 97%), and the median chest compression fraction (0.81 to 0.87). There was a significant increase in the median time until termination of resuscitation in those who did not achieve ROSC (27 to 32 minutes), and a significant decrease in the proportion of patients who were transported in absence of ROSC (17% to 6.5%). There was a significant improvement in achieving ROSC (44% to 48%; adjusted rate ratio per year 1.02, 95% CI 1.01 to 1.02) and survival at hospital discharge (10% to 14%; adjusted rate ratio per year 1.05, 95% CI 1.04 to 1.06). Both subgroups of initial shockable (adjusted rate ratio per year 1.04, 95% CI 1.03 to 1.05) and non-shockable (adjusted rate ratio per year 1.08, 95% CI 1.06 to 1.12) cardiac rhythms demonstrated survival improvement. Conclusion: Despite a significant decrease in those with initial shockable rhythms, out-of-hospital cardiac arrest survival in BC’s metropolitan regions increased by approximately 40% over a 10-year period. During this time there were system changes and quality of care improvements as provided by bystanders and professionals.

Introduction: Sodium bicarbonate (SB) is still widely used for resuscitation in out-of- hospital cardiac arrest (OHCA) despite limited clinical indications but the effect on neurological recovery is unclear. Methods: From 2006 to 2016, we prospectively conducted a province-wide population-based observational study of adult non-traumatic OHCA patients managed by EMS. According to provincial guidelines, paramedics administered SB to OHCA patients based on their clinical assessment. Outcome of interest was favorable neurological outcome at hospital discharge, defined as CPC of 1 and 2 or modified Rankin scale of 3 or less. We performed multivariable logistic regression, comparing the proportion of outcome between SB and non-SB groups, further stratified by the median of the length of resuscitation. We also applied propensity score matching technique adjusting for baseline characters to the same model to reduce potential selection bias. Results: Of 13,008 OHCA patients, 4,699 (36.1%) were managed with SB. In the SB treated group, 64 / 4,699 (1.3%) patients had favorable neurological outcomes, compared to 823 / 8,309 (9.9%) in the non-SB treated group (crude odds ratio [OR] 0.12, 95% CI 0.09 to 0.16). In logistic regression model, SB was associated with decreased probability of favorable outcomes (adjusted OR 0.63, 95% CI 0.45 to 0.89). Similarly, with stratification by length of resuscitation, the SB group had a lower probability of favorable outcomes (≦24 min: adjusted OR 0.68, 95% CI 0.46 to 1.02, >24 min: adjusted OR 0.47, 95% CI 0.23 to 0.97). In 1:1 propensity matched cohort including 5,126 OHCA patients, the adjusted association also persisted (adjusted OR 0.59, 95% CI 0.39 to 0.89). Conclusion: Prehospital administration of SB to OHCA patients was associated with worse neurological outcomes and the trend persisted even after stratification by resuscitation length.