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Bendamustine and rituximab (BR) is a preferred first-line therapy for indolent non-Hodgkin's lymphoma (iNHL) and mantle cell lymphoma (MCL); however, few reports on BR performance in elderly patients are available to date. We compared safety and efficacy of BR in patients ≥70 years (elderly) vs70 years (younger) treated at our institution. Among 201 patients, 113 were elderly (median age: 77 years), including 38 patients ≥80 years, and 88 were younger (median age: 62 years). Elderly patients had more bone marrow involvement by lymphoma, anemia, ECOG status 3, and high-risk disease follicular lymphoma (p0.05 for all). Fifty-four percent of elderly received full dose of bendamustine vs 79.5% of younger patients. More elderly patients (54%) vs younger (43.2%) experienced treatment delay. Less elderly proceeded to rituximab maintenance. Overall, the number of adverse events per patient and transformed B-Cell lymphoma/secondary malignancies were similar between groups. Elderly patients had less febrile neutropenia, rituximab-associated infusion reactions, but more herpes zoster reactivation. There were more deaths in the elderly (37.2%) vs younger (10.2%) groups (p0.001), mainly due to non-lymphoma-related causes. With median follow-up of 42 months [4.0-97.0] disease-free survival for the elderly was similar to younger patients. There was no difference between patients80 and ≥80 years (p=0.274). In conclusion, the real-world elderly patients have more advanced disease and higher ECOG status. BR is well-tolerated; elderly patients had lower incidence of febrile neutropenia. Dose reduction and treatment delays are common, but BR efficacy was not affected even in very old patients (≥80 years).

BackgroundPredefibrillation end-tidal CO2(ETCO2) may predict defibrillation success and could guide defibrillation timing in ventricular fibrillation (VF) cardiac arrest. This relationship has only been studied using advanced airways. Our aim was to evaluate this relationship using both basic (bag–valve–mask (BVM)) and advanced airways (supraglottic airways and endotracheal tubes).MethodsPrehospital patient records and defibrillator files were abstracted for patients with out-of-hospital cardiac arrest in Ontario, Canada, with initial VF cardiac rhythms between 1 January 2018, and 31 December 2019. Analyses assessed the relationship between each predefibrillation ETCO2reading and defibrillation outcomes at the subsequent 2 min pulse check (ie, VF, asystole, pulseless electrical activity (PEA) or return of spontaneous circulation (ROSC)), accounting for airway types used during resuscitation. Multivariable logistic regression evaluated the association between the first documented predefibrillation ETCO2and postshock VF termination or ROSC.ResultsOf 269 cases abstracted, 153 had predefibrillation ETCO2measurements and were included in the study. Among these cases, 904 shocks were delivered and 44.4% (n=401) had predefibrillation ETCO2measured. The first ETCO2reading was more often from BVM (n=134) than advanced airways (n=19). ETCO2readings were lower when measured through BVM versus advanced airways (30.5 mm Hg (4.06 kPa) (±14.4 mm Hg (1.92 kPa)) vs 42.1 mm Hg (5.61 kPa) (±22.5 mm Hg (3.00 kPa)),adjANOVA p2reading (n=401), no difference in preshock ETCO2was found for subsequent shocks that resulted in persistent VF (32.2 mm Hg (4.29 kPa) (±15.8 mm Hg (2.11 kPa))), PEA (32.8 mm Hg (4.37 kPa) (±17.1 mm Hg (2.30 kPa))), asystole (32.4 mm Hg (4.32 kPa) (±20.6 mm Hg (2.75 kPa))) or ROSC (32.5 mm Hg (4.33 kPa) (±15.3 mm Hg (2.04 kPa))), analysis of variance p=0.99. In the multivariate analysis using the initial predefibrillation ETCO2, there was no association with VF termination on the subsequent shock (adjusted OR (adjOR) 0.99, 95% CI 0.97 to 1.02, p=0.57) or ROSC (adjOR 1.00, 95% CI 0.97 to 1.03, p=0.94) when evaluated as a continuous or categorical variable.ConclusionPredefibrillation ETCO2measurement is not associated with VF termination or ROSC when basic and advanced airways are included in the analysis. The role of predefibrillation ETCO2requires careful consideration of the type of airway used during resuscitation.

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.

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.

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.

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.

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.

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.

The modified Valsalva maneuver has been promoted as a safe and effective method for the treatment of supraventricular tachycardia. Serious adverse events associated with the modified Valsalva maneuver are not well documented. Here we report a case of non-sustained polymorphic ventricular tachycardia in a pregnant patient associated with the use of the modified Valsalva maneuver by paramedics in the prehospital setting.

Predefibrillation end-tidal COPrehospital patient records and defibrillator files were abstracted for patients with out-of-hospital cardiac arrest in Ontario, Canada, with initial VF cardiac rhythms between 1 January 2018, and 31 December 2019. Analyses assessed the relationship between each predefibrillation ETCOOf 269 cases abstracted, 153 had predefibrillation ETCOPredefibrillation ETCO

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.

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.

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.

Double sequential external defibrillation (DSED) is a novel treatment option for cardiac arrest patients in refractory ventricular fibrillation (VF). There is limited research, however, examining the efficacy of this treatment in clinical practice. Previous research is further confounded by the use of other treatments such as advanced cardiac life support medications. We present the case of the successful use of DSED for refractory out-of-hospital cardiac arrest without the use of advanced life support care.

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.

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.