RESUMEN
OBJECTIVE: This study aimed to assess the benefits of adding a physician-staffed ambulance to bystander-witnessed out-of-hospital cardiac arrest using a community-based registry. DESIGN: Population-based, retrospective cohort study. SETTING: An urban city with approximately 800 000 residents. PARTICIPANTS: Patients aged ≥18 years with bystander-witnessed out-of-hospital cardiac arrests of medical aetiology in Niigata City, Japan, between January 2012 and December 2016, according to the Utstein style. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was 1-month survival with a favourable neurological outcome, defined as a cerebral performance category score of 1 or 2. We used logistic regression analysis to assess the association between favourable neurological outcome and prehospital physician involvement. RESULTS: During the study period, a total of 4172 cardiac arrests were registered; of these, 892 patients with out-of-hospital cardiac arrest were eligible for this analysis, among whom 135 (15.1%) had prehospital physician involvement and 757 (84.9%) did not have prehospital physician involvement. The percentage of favourable neurological outcomes was 20.7% (28 of 135) in those with physician involvement and 10.4% (79 of 757) in those without physician involvement (p=0.001). Using multivariable logistic regression, prehospital physician involvement had an OR for a favourable neurological outcome of 3.44 (95% CI 1.64 to 7.23). CONCLUSIONS: Among adults with out-of-hospital cardiac arrest, adding a physician-staffed ambulance was associated with significantly greater favourable neurological outcomes than standard emergency medical services.
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Apoyo Vital Cardíaco Avanzado/mortalidad , Ambulancias/organización & administración , Reanimación Cardiopulmonar/mortalidad , Paro Cardíaco Extrahospitalario/mortalidad , Paro Cardíaco Extrahospitalario/terapia , Adolescente , Adulto , Apoyo Vital Cardíaco Avanzado/métodos , Apoyo Vital Cardíaco Avanzado/tendencias , Anciano , Anciano de 80 o más Años , Reanimación Cardiopulmonar/tendencias , Femenino , Humanos , Japón/epidemiología , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Médicos , Sistema de Registros , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Resultado del Tratamiento , Adulto JovenRESUMEN
INTRODUCTION: Presence of electrocardiographic rhythm in the absence of palpable pulses defines pulseless electrical activity (PEA) and the electrocardiogram (ECG) may provide a source of information during resuscitation. The aim of this study was to examine the development of ECG characteristics during advanced life support (ALS) from Out-of-hospital cardiac arrest (OHCA) with initial PEA, and to explore the potential effects of adrenaline on these characteristics. METHODS: Patients with OHCA and initial PEA, part of randomized controlled trial of ALS with or without intravenous access and medications, were included. A total of 4840 combined observations of QRS complex rate (heart rate) and width were made by examining defibrillator recordings from 170 episodes of cardiac arrest. RESULTS: We found Increased heart rate (47 beats per minute) and reduced QRS complex width (62 ms) during ALS in patients who obtained return of spontaneous circulation (ROSC); while patients who received adrenaline but died increased their heart rate (22 beats per minute) without any concomitant decrease in QRS complex width. CONCLUSION: ECG changes during ALS in cardiac arrest were associated with prognosis, and the administration of adrenaline impacted on these changes.
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Agonistas Adrenérgicos beta/administración & dosificación , Apoyo Vital Cardíaco Avanzado/métodos , Epinefrina/administración & dosificación , Paro Cardíaco Extrahospitalario/terapia , Administración Intravenosa , Apoyo Vital Cardíaco Avanzado/mortalidad , Electrocardiografía , Femenino , Frecuencia Cardíaca/efectos de los fármacos , Humanos , Masculino , Paro Cardíaco Extrahospitalario/mortalidadRESUMEN
OBJECTIVE: To compare the survival to discharge between nursing home (NH) cardiac arrest patients receiving smartphone-based advanced cardiac life support (SALS) and basic life support (BLS). METHODS: The SALS registry includes data on cardiac arrest from 7 urban and suburban areas in Korea between July 2015 and December 2016. We include adult patients (>18) with out-of-hospital cardiac arrest (OHCA) of medical causes and EMS attended and dispatched in. SALS is an advanced field resuscitation including drug administration by paramedics with video communication-based direct medical direction. Prehospital resuscitation method was key exposure (SALS, BLS). The primary outcome was survival to discharge. RESULTS: A total of 616 consecutive out-of-hospital cardiopulmonary resuscitation cases in NHs were recorded, and 199 (32.3%) underwent SALS. Among the NH arrest patients, the survival discharge rate was a little higher in the SALS group than the BLS group (4.0% vs 1.7%), but the difference was not significant (Pâ¯=â¯0.078). Survival discharge with good neurologic outcome rates was 0.5% in the SALS group and 1.0% in the BLS group (Pâ¯=â¯0.119). On the other hand, in the non-NH group, all outcome measures significantly improved when SALS was performed compared to BLS alone (survival discharge rate: 10.0% vs 7.3%, Pâ¯=â¯0.001; good neurologic outcome: 6.8% vs 3.3%, Pâ¯<â¯0.001). CONCLUSIONS: As a result of providing prehospital ACLS with direct medical intervention through remote video calls to paramedics, the survival to discharge rate and that with good neurologic outcome (CPC 1, 2) of non-NH patients significantly improved, however those of NH patients were not significantly increased.
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Apoyo Vital Cardíaco Avanzado/mortalidad , Apoyo Vital Cardíaco Avanzado/métodos , Servicios Médicos de Urgencia/métodos , Paro Cardíaco Extrahospitalario/mortalidad , Teléfono Inteligente , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Casas de Salud , Paro Cardíaco Extrahospitalario/terapia , Sistema de Registros , República de Corea/epidemiología , Estudios Retrospectivos , Tasa de SupervivenciaRESUMEN
BACKGROUND: Prior observational studies suggest no additional benefit from advanced life support (ALS) when compared with providing basic life support (BLS) for patients with out-of-hospital cardiac arrest (OHCA). We compared the association of ALS care with OHCA outcomes using prospective clinical data from the Resuscitation Outcomes Consortium (ROC). METHODS: Included were consecutive adults OHCA treated by participating emergency medical services (EMS) agencies between June 1, 2011, and June 30, 2015. We defined BLS as receipt of cardiopulmonary resuscitation (CPR) and/or automated defibrillation and ALS as receipt of an advanced airway, manual defibrillation, or intravenous drug therapy. We compared outcomes among patients receiving: 1) BLS-only; 2) BLSâ¯+â¯late ALS; 3) BLSâ¯+â¯early ALS; and 4) ALS-first care. Using multivariable logistic regression, we evaluated the associations between level of care and return of spontaneous circulation (ROSC), survival to hospital discharge, and survival with good functional status, adjusting for age, sex, witnessed arrest, bystander CPR, shockable initial rhythm, public location, EMS response time, CPR quality, and ROC site. RESULTS: Among 35,065 patients with OHCA, characteristics were median age 68 years (IQR 56-80), male 63.9%, witnessed arrest 43.8%, bystander CPR 50.6%, and shockable initial rhythm 24.2%. Care delivered was: 4.0% BLS-only, 31.5% BLSâ¯+â¯late ALS, 17.2% BLSâ¯+â¯early ALS, and 47.3% ALS-first. ALS care with or without initial BLS care was independently associated with increased adjusted ROSC and survival to hospital discharge unless delivered greater than 6â¯min after BLS arrival (BLSâ¯+â¯late ALS). Regardless of when it was delivered, ALS care was not associated with significantly greater functional outcome. CONCLUSION: ALS care was associated with survival to hospital discharge when provided initially or within six minutes of BLS arrival. ALS care, with or without initial BLS care, was associated with increased ROSC, however it was not associated with functional outcome.
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Apoyo Vital Cardíaco Avanzado/mortalidad , Paro Cardíaco Extrahospitalario/mortalidad , Adulto , Apoyo Vital Cardíaco Avanzado/métodos , Anciano , Anciano de 80 o más Años , Reanimación Cardiopulmonar/métodos , Reanimación Cardiopulmonar/mortalidad , Desfibriladores , Cardioversión Eléctrica , Servicios Médicos de Urgencia/estadística & datos numéricos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Paro Cardíaco Extrahospitalario/terapia , Estudios Retrospectivos , Factores de TiempoRESUMEN
BACKGROUND: Outcome is generally poor in out of hospital cardiac arrests (OHCA) with initial non-shockable rhythms. Termination of resuscitation rules facilitate early prognostication at the scene to cease resuscitation attempts in futile situations and to proceed advanced life support in promising conditions. As pulseless electrical activity (PEA) is present as first rhythm in every 4th OHCA we were interested if the initial electrical frequency in PEA predicts survival. METHODS: All patients >18â¯years of age with non-traumatic OHCA and PEA as first rhythm between August 2013 and August 2015 from the Vienna Cardiac Arrest Registry were included in this retrospective observational study. Defibrillator and epidemiological data from the emergency medical system as survival data were processed considering the initial electrical activity in PEA and 30â¯days survival. RESULTS: Out of 2149 OHCA patients, a total of 504 PEA patients were eligible for analyses. These patients were stratified into 4 groups according the initial electrical frequency in PEA: 10-24/min, 25-39/min, 40-59/min, >60/min. Compared to a frequency >60/min all other subgroups were associated with higher mortality especially those with an initial electrical frequency 10-24 (adjusted OR 0.56 (0.39-0.79) pâ¯=â¯.001 for each category chance). QRS duration in PEA did not influence outcome. Patients in the >60/min group showed a 30-days-survival rate of 22% and a good neurological outcome in 15% of all patients - comparable to shockable cardiac arrest rhythms. CONCLUSION: Regardless of other resuscitation factors, higher initial electrical frequency in PEA is associated with increased odds of survival and good neurological outcome.
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Apoyo Vital Cardíaco Avanzado/métodos , Cardioversión Eléctrica/métodos , Paro Cardíaco Extrahospitalario/mortalidad , Paro Cardíaco Extrahospitalario/terapia , Apoyo Vital Cardíaco Avanzado/mortalidad , Anciano , Anciano de 80 o más Años , Servicios Médicos de Urgencia/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Paro Cardíaco Extrahospitalario/fisiopatología , Evaluación de Resultado en la Atención de Salud , Sistema de Registros , Estudios Retrospectivos , Análisis de Supervivencia , Factores de Tiempo , Tiempo de TratamientoRESUMEN
OBJECTIVE: Little is known about treatments provided by advanced life support (ALS) ambulance teams to patients with acute heart failure (AHF) during the prehospital phase, and their influence on short-term outcome. We evaluated the effect of prehospital care in consecutive patients diagnosed with AHF in Spanish emergency departments (EDs). METHODS: We selected patients from the EAHFE registry arriving at the ED by ALS ambulances with available follow-up data. We recorded specific prehospital ALS treatments (supplemental oxygen, diuretics, nitroglycerin, non-invasive ventilation) and patients were grouped according to whether they received low- (LIPHT; 0/1 treatments) or high-intensity prehospital therapy (HIPHT; > 1 treatment) for AHF. We also recorded 46 covariates. The primary endpoint was all-cause 7-day mortality, and secondary endpoints were prolonged hospitalisation (> 10 days) and in-hospital and 30-day mortality. Unadjusted and adjusted odds ratios were calculated to compare the groups. RESULTS: We included 1493 patients [mean age 80.7 (10) years; women 54.8%]. Prehospital treatment included supplemental oxygen in 71.2%, diuretics in 27.9%, nitroglycerin in 13.5%, and non-invasive ventilation in 5.3%. The LIPHT group included 1041 patients (70.0%) with an unadjusted OR for 7-day mortality of 1.770 (95% CI 1.115-2.811; p = 0.016), and 1.939 (95% CI 1.114-3.287, p = 0.014) after adjustment for 16 discordant covariables. The adjusted ORs for all secondary endpoints were always > 1 in the LIPHT group, but none reached statistical significance. CONCLUSIONS: Patients finally diagnosed with AHF at then ED that have received LIPHT by the ALS ambulance teams have a poorer short-term outcome, especially during the first 7 days.
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Servicios Médicos de Urgencia , Insuficiencia Cardíaca/terapia , Enfermedad Aguda , Apoyo Vital Cardíaco Avanzado/efectos adversos , Apoyo Vital Cardíaco Avanzado/mortalidad , Anciano , Anciano de 80 o más Años , Distribución de Chi-Cuadrado , Terapia Combinada , Femenino , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/fisiopatología , Mortalidad Hospitalaria , Humanos , Tiempo de Internación , Modelos Logísticos , Masculino , Oportunidad Relativa , Sistema de Registros , Factores de Riesgo , España , Factores de Tiempo , Resultado del TratamientoRESUMEN
This retrospective cohort study examined the rate of survival to hospital discharge among adult patients with out-of-hospital cardiac arrest, comparing patients who received care only from basic cardiac life support (BCLS)-trained emergency medical service (EMS) crews to patients who had an advanced cardiac life support (ACLS)-trained EMS crew on scene at some point during the resuscitation. There was no difference in the primary outcome of rate of survival to hospital discharge (10.9% with ACLS care and 10.6% with BCLS care, p = 0.67).
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Reanimación Cardiopulmonar/mortalidad , Servicios Médicos de Urgencia/organización & administración , Paro Cardíaco Extrahospitalario/mortalidad , Paro Cardíaco Extrahospitalario/terapia , Adulto , Apoyo Vital Cardíaco Avanzado/métodos , Apoyo Vital Cardíaco Avanzado/mortalidad , Anciano , Reanimación Cardiopulmonar/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Alta del Paciente , Estudios Retrospectivos , Análisis de SupervivenciaRESUMEN
INTRODUCTION: Sodium nitroprusside (SNP) enhanced CPR (SNPeCPR) demonstrates increased vital organ blood flow and survival in multiple porcine models. We developed a new, coronary occlusion/ischemia model of prolonged resuscitation, mimicking the majority of out-of-hospital cardiac arrests presenting with shockable rhythms. HYPOTHESIS: SNPeCPR will increase short term (4-h) survival compared to standard 2015 Advanced Cardiac Life Support (ACLS) guidelines in an ischemic refractory ventricular fibrillation (VF), prolonged CPR model. METHODS: Sixteen anesthetized pigs had the ostial left anterior descending artery occluded leading to ischemic VF arrest. VF was untreated for 5min. Basic life support was performed for 10min. At minute 10 (EMS arrival), animals received either SNPeCPR (n=8) or standard ACLS (n=8). Defibrillation (200J) occurred every 3min. CPR continued for a total of 45min, then the balloon was deflated simulating revascularization. CPR continued until return of spontaneous circulation (ROSC) or a total of 60min, if unsuccessful. SNPeCPR animals received 2mg of SNP at minute 10 followed by 1mg every 5min until ROSC. Standard ACLS animals received 0.5mg epinephrine every 5min until ROSC. Primary endpoints were ROSC and 4-h survival. RESULTS: All SNPeCPR animals (8/8) achieved sustained ROSC versus 2/8 standard ACLS animals within one hour of resuscitation (p=0.04). The 4-h survival was significantly improved with SNPeCPR compared to standard ACLS, 7/8 versus 1/8 respectively, p=0.0019. CONCLUSION: SNPeCPR significantly improved ROSC and 4-h survival compared with standard ACLS CPR in a porcine model of prolonged ischemic, refractory VF cardiac arrest.
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Paro Cardíaco , Isquemia Miocárdica , Nitroprusiato/administración & dosificación , Flujo Sanguíneo Regional/efectos de los fármacos , Fibrilación Ventricular/complicaciones , Apoyo Vital Cardíaco Avanzado/métodos , Apoyo Vital Cardíaco Avanzado/mortalidad , Animales , Reanimación Cardiopulmonar/métodos , Modelos Animales de Enfermedad , Esquema de Medicación , Monitoreo de Drogas/métodos , Cardioversión Eléctrica/métodos , Paro Cardíaco/etiología , Paro Cardíaco/terapia , Isquemia Miocárdica/tratamiento farmacológico , Isquemia Miocárdica/etiología , Isquemia Miocárdica/fisiopatología , Análisis de Supervivencia , Porcinos , Factores de Tiempo , Resultado del Tratamiento , Vasodilatadores/administración & dosificación , Fibrilación Ventricular/fisiopatología , Fibrilación Ventricular/terapiaRESUMEN
We validated the basic life support termination of resuscitation (BLS TOR) rule retrospectively using Out-of-Hospital Cardiac Arrest (OHCA) data of metropolitan emergency medical service (EMS) in Korea. We also tested it by investigating the scene time interval for supplementing the BLS TOR rule. OHCA database of Seoul (January 2011 to December 2012) was used, which is composed of ambulance data and hospital medical record review. EMS-treated OHCA and 19 yr or older victims were enrolled, after excluding cases occurred in the ambulance and with incomplete information. The primary and secondary outcomes were hospital mortality and poor neurologic outcome. After calculating the sensitivity (SS), specificity (SP), and the positive and negative predictive values (PPV and NPV), tested the rule according to the scene time interval group for sensitivity analysis. Of total 4,835 analyzed patients, 3,361 (69.5%) cases met all 3 criteria of the BLS TOR rule. Of these, 3,224 (95.9%) were dead at discharge (SS,73.5%; SP,69.6%; PPV,95.9%; NPV, 21.3%) and 3,342 (99.4%) showed poor neurologic outcome at discharge (SS, 75.2%; SP, 89.9%; PPV, 99.4%; NPV, 11.5%). The cut-off scene time intervals for 100% SS and PPV were more than 20 min for survival to discharge and more than 14 min for good neurological recovery. The BLS TOR rule showed relatively lower SS and PPV in OHCA data in Seoul, Korea.
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Apoyo Vital Cardíaco Avanzado/mortalidad , Reanimación Cardiopulmonar/mortalidad , Cardioversión Eléctrica/mortalidad , Paro Cardíaco Extrahospitalario/epidemiología , Paro Cardíaco Extrahospitalario/mortalidad , Adulto , Cuidados Críticos/estadística & datos numéricos , Técnicas de Apoyo para la Decisión , Servicios Médicos de Urgencia , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Paro Cardíaco Extrahospitalario/terapia , Negativa al Tratamiento , República de Corea/epidemiología , Estudios Retrospectivos , Tasa de Supervivencia , Factores de Tiempo , Tiempo de Tratamiento , Resultado del TratamientoRESUMEN
We validated the basic life support termination of resuscitation (BLS TOR) rule retrospectively using Out-of-Hospital Cardiac Arrest (OHCA) data of metropolitan emergency medical service (EMS) in Korea. We also tested it by investigating the scene time interval for supplementing the BLS TOR rule. OHCA database of Seoul (January 2011 to December 2012) was used, which is composed of ambulance data and hospital medical record review. EMS-treated OHCA and 19 yr or older victims were enrolled, after excluding cases occurred in the ambulance and with incomplete information. The primary and secondary outcomes were hospital mortality and poor neurologic outcome. After calculating the sensitivity (SS), specificity (SP), and the positive and negative predictive values (PPV and NPV), tested the rule according to the scene time interval group for sensitivity analysis. Of total 4,835 analyzed patients, 3,361 (69.5%) cases met all 3 criteria of the BLS TOR rule. Of these, 3,224 (95.9%) were dead at discharge (SS,73.5%; SP,69.6%; PPV,95.9%; NPV, 21.3%) and 3,342 (99.4%) showed poor neurologic outcome at discharge (SS, 75.2%; SP, 89.9%; PPV, 99.4%; NPV, 11.5%). The cut-off scene time intervals for 100% SS and PPV were more than 20 min for survival to discharge and more than 14 min for good neurological recovery. The BLS TOR rule showed relatively lower SS and PPV in OHCA data in Seoul, Korea.
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Adulto , Femenino , Humanos , Masculino , Apoyo Vital Cardíaco Avanzado/mortalidad , Reanimación Cardiopulmonar/mortalidad , Cuidados Críticos/estadística & datos numéricos , Técnicas de Apoyo para la Decisión , Cardioversión Eléctrica/mortalidad , Servicios Médicos de Urgencia , Mortalidad Hospitalaria , Paro Cardíaco Extrahospitalario/epidemiología , Negativa al Tratamiento , República de Corea/epidemiología , Estudios Retrospectivos , Tasa de Supervivencia , Factores de Tiempo , Tiempo de Tratamiento , Resultado del TratamientoRESUMEN
In recent years the range of products for extracorporeal lung support has substantially expanded. In principle systems generating high blood flow and thus enabling oxygenation and decarboxylation, corresponding to classical extracorporeal membrane oxygenation (ECMO), can be distinguished from low-flow systems, enabling decarboxylation only. Technical progress and new data have led to a novel insight into the role of ECMO as an invasive, ultimate therapy in refractory life-threatening lung failure towards a broader range of applications even in spontaneously breathing and awake patients. Indications for extracorporeal decarboxylation, initially thought to enable most protective ventilator settings, have been extended to forms of hypercapnic lung failure and towards avoidance of intubation and mechanical ventilation itself in patients with isolated hypercapnia and failure of non-invasive ventilation. It has to be emphasized however, that due to a still sparse amount of literature and potentially deleterious complications associated with extracorporeal lung support, these kinds of therapies should be reserved for specialized and experienced centers.
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Apoyo Vital Cardíaco Avanzado/métodos , Cuidados Críticos/métodos , Oxigenación por Membrana Extracorpórea/métodos , Insuficiencia Respiratoria/terapia , Apoyo Vital Cardíaco Avanzado/efectos adversos , Apoyo Vital Cardíaco Avanzado/instrumentación , Apoyo Vital Cardíaco Avanzado/mortalidad , Austria , Dióxido de Carbono/sangre , Oxigenación por Membrana Extracorpórea/efectos adversos , Oxigenación por Membrana Extracorpórea/instrumentación , Oxigenación por Membrana Extracorpórea/mortalidad , Humanos , Hipercapnia/mortalidad , Hipercapnia/fisiopatología , Hipercapnia/terapia , Pulmón/fisiopatología , Oxígeno/sangre , Insuficiencia Respiratoria/mortalidad , Tasa de Supervivencia , Centros de Atención TerciariaRESUMEN
AIM: To evaluate the usefulness of routine laboratory parameters in the decision to treat refractory cardiac arrest patients with extracorporeal life support (ECLS). METHODS: Sixty-six adults with witnessed cardiac arrest of cardiac origin unrelated to poisoning or hypothermia undergoing cardiopulmonary resuscitation without return of spontaneous circulation (duration: 155 min [120-180], median, [25-75%-percentiles]) were included in a prospective cohort-study. ECLS was implemented under cardiac massage, using a centrifugal pump connected to a hollow-fiber membrane-oxygenator, aiming to maintain ECLS flow ≥ 2.5 l/min and mean arterial pressure ≥ 60 mm Hg. RESULTS: Forty-seven of 66 patients died within 24 h from multiorgan failure and massive capillary leak. Of 19/66 patients who survived ≥ 24 h with stable circulatory conditions permitting neurological evaluation, four became conscious and were transferred for further cardiac assistance, while three became organ donors. Ultimately, one patient survived without neurologic sequelae after cardiac transplantation. Using multivariate analysis, only pre-cannulation peripheral venous oxygen saturation (SpvO2, 28% [15-52]) independently predicted inability to maintain targeted ECLS conditions ≥ 24 h (odds ratio for each 10%-decrease [95%-confidence interval]: 1.65 [1.21; 2.25], p=0.002). The area under the receiver-operating-characteristics curve was 0.78 [0.63; 0.93]. SpvO2 cut-off value of 33% was associated with a sensitivity of 0.68 [0.50; 0.83] and specificity of 0.81 [0.54; 0.96]. SpvO2 ≤ 8%, lactate concentration ≥ 21 mmol/l, fibrinogen ≤ 0.8 g/l, and prothrombin index ≤ 11% predicted premature ECLS discontinuation with a specificity of 1. CONCLUSION: SpvO2 is useful to predict the inability of maintaining refractory cardiac arrest victims on ECLS without detrimental capillary leak and multiorgan failure until neurological evaluation.
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Causas de Muerte , Pruebas Diagnósticas de Rutina/estadística & datos numéricos , Oxigenación por Membrana Extracorpórea/mortalidad , Oxigenación por Membrana Extracorpórea/métodos , Paro Cardíaco/diagnóstico , Paro Cardíaco/terapia , Adulto , Apoyo Vital Cardíaco Avanzado/métodos , Apoyo Vital Cardíaco Avanzado/mortalidad , Análisis de Varianza , Reanimación Cardiopulmonar/métodos , Reanimación Cardiopulmonar/mortalidad , Distribución de Chi-Cuadrado , Estudios de Cohortes , Toma de Decisiones , Femenino , Francia , Escala de Coma de Glasgow , Paro Cardíaco/mortalidad , Humanos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Estudios Prospectivos , Curva ROC , Retratamiento/métodos , Medición de Riesgo , Índice de Severidad de la Enfermedad , Estadísticas no Paramétricas , Tasa de Supervivencia , Insuficiencia del TratamientoRESUMEN
Evidence for the impact of prehospital, physician-delivered advanced cardiac life support (ACLS) on survival from out-of-hospital cardiac arrest is conflicting. The prospective observational study by Yasunaga and co-workers demonstrates an improved survival at 1 month associated with prehospital physician-delivered ACLS over emergency life-saving technician-delivered ACLS. These effects are additive to the survival benefit seen with bystander-initiated cardiopulmonary resuscitation (BCPR) compared with no BCPR. The present commentary places these findings in the context of the existing literature and discusses some of the unresolved controversies.
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Apoyo Vital Cardíaco Avanzado/mortalidad , Reanimación Cardiopulmonar/mortalidad , Conducta Cooperativa , Paro Cardíaco Extrahospitalario/mortalidad , Paro Cardíaco Extrahospitalario/terapia , Médicos , Vigilancia de la Población , Femenino , Humanos , MasculinoRESUMEN
BACKGROUND: Little data exists on whether the physicians' skills in responding to cardiac arrest are fully developed after the advanced cardiac life support (ACLS) course, or if there is a significant improvement in their performance after an initial learning curve. OBJECTIVE: To estimate the effect of physician experience on the results of prehospital cardiac arrests. MATERIALS AND METHODS: Prospective data were collected on all prehospital resuscitative attempts in the area by ACLS-trained ambulance physicians. RESULTS: Of 232 attempted cardiac resuscitations, 96 (41%) patients survived to hospital admission and 44 (19%) were discharged alive. A group of 39 physicians responded to from one up to 29 cases with a mean of four cases. Physicians responding to five or fewer cases had a trend to fewer patients surviving to admission compared with those responding to six or more (36 vs. 45%, P=0.31) but no difference was found on survival to discharge (19 vs. 20%, P=0.87). CONCLUSION: In this study, resuscitative experience of the physician did not have a significant effect on survival suggesting that experience does not significantly add to the current ACLS training in responding to ventricular fibrillation/ventricular tachycardia. More studies are needed.
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Apoyo Vital Cardíaco Avanzado/educación , Apoyo Vital Cardíaco Avanzado/mortalidad , Causas de Muerte , Competencia Clínica , Paro Cardíaco Extrahospitalario/mortalidad , Adulto , Anciano , Anciano de 80 o más Años , Reanimación Cardiopulmonar/educación , Reanimación Cardiopulmonar/mortalidad , Distribución de Chi-Cuadrado , Bases de Datos Factuales , Servicios Médicos de Urgencia/normas , Servicios Médicos de Urgencia/tendencias , Medicina de Emergencia/educación , Medicina de Emergencia/tendencias , Femenino , Humanos , Islandia , Masculino , Persona de Mediana Edad , Paro Cardíaco Extrahospitalario/terapia , Pautas de la Práctica en Medicina , Estudios Prospectivos , Calidad de la Atención de Salud , Medición de Riesgo , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
INTRODUCTION: There are inconsistent data about the effectiveness of prehospital physician-staffed advanced cardiac life support (ACLS) on the outcomes of out-of-hospital cardiac arrest (OHCA). Furthermore, the relative importance of bystander-initiated cardiopulmonary resuscitation (BCPR) and ACLS and the effectiveness of their combination have not been clearly demonstrated. METHODS: Using a prospective, nationwide, population-based registry of all OHCA patients in Japan, we enrolled 95,072 patients whose arrests were witnessed by bystanders and 23,127 patients witnessed by emergency medical service providers between 2005 and 2007. We divided the bystander-witnessed arrest patients into Group A (ACLS by emergency life-saving technicians without BCPR), Group B (ACLS by emergency life-saving technicians with BCPR), Group C (ACLS by physicians without BCPR) and Group D (ACLS by physicians with BCPR). The outcome data included 1-month survival and neurological outcomes determined by the cerebral performance category. RESULTS: Among the 95,072 bystander-witnessed arrest patients, 7,722 (8.1%) were alive at 1 month, including 2,754 (2.9%) with good performance and 3,171 (3.3%) with vegetative status or worse. BCPR occurred in 42% of bystander-witnessed arrests. In comparison with Group A, the rates of good-performance survival were significantly higher in Group B (odds ratio (OR), 2.23; 95% confidence interval, 2.05 to 2.42; P < 0.01) and Group D (OR, 2.80; 95% confidence interval, 2.28 to 3.43; P < 0.01), while no significant difference was seen for Group C (OR, 1.18; 95% confidence interval, 0.86 to 1.61; P = 0.32). The occurrence of vegetative status or worse at 1 month was highest in Group C (OR, 1.92; 95% confidence interval, 1.55 to 2.37; P < 0.01). CONCLUSIONS: In this registry-based study, BCPR significantly improved the survival of OHCA with good cerebral outcome. The groups with BCPR and ACLS by physicians had the best outcomes. However, receiving ACLS by physicians without preceding BCPR significantly increased the number of patients with neurologically unfavorable outcomes.
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Apoyo Vital Cardíaco Avanzado/mortalidad , Reanimación Cardiopulmonar/mortalidad , Conducta Cooperativa , Paro Cardíaco Extrahospitalario/mortalidad , Paro Cardíaco Extrahospitalario/terapia , Médicos , Vigilancia de la Población , Apoyo Vital Cardíaco Avanzado/métodos , Apoyo Vital Cardíaco Avanzado/tendencias , Anciano , Anciano de 80 o más Años , Reanimación Cardiopulmonar/tendencias , Femenino , Humanos , Japón/epidemiología , Masculino , Persona de Mediana Edad , Médicos/tendencias , Vigilancia de la Población/métodos , Estudios Prospectivos , Sistema de Registros , Tasa de Supervivencia/tendencias , Resultado del TratamientoAsunto(s)
Reanimación Cardiopulmonar/métodos , Oxigenación por Membrana Extracorpórea/métodos , Paro Cardíaco/mortalidad , Paro Cardíaco/terapia , Mortalidad Hospitalaria/tendencias , Apoyo Vital Cardíaco Avanzado/métodos , Apoyo Vital Cardíaco Avanzado/mortalidad , Reanimación Cardiopulmonar/mortalidad , Causas de Muerte , Estudios de Cohortes , Oxigenación por Membrana Extracorpórea/mortalidad , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
OBJECTIVES: To study the factors associated with short- and long-term survival after asystolic out-of-hospital cardiac arrest, with a reference to medical futility. METHODS: This is a retrospective observational study conducted in Helsinki, Finland during 1 January 1997 to 31 December 2005. All out-of-hospital cardiac arrests were prospectively registered in the cardiac arrest database. Of 3291 arrests, 1455 had asystole as the first registered rhythm. These patients represent the study population. RESULTS: A short time interval to the initiation of advanced life support (ALS) was associated with a long-term benefit, but a short first responding unit (FRU) response time had only a short-term benefit. Conversion of asystole into a shockable rhythm provided only a short-term benefit. The prognosis was poor if the FRU response time was over 10 min or the ALS response time was over 11 min in bystander-witnessed arrests, and if the duration of resuscitation was over 8 min in emergency medical services (EMS)-witnessed arrests. Bystander-CPR was associated with increased 30-day mortality. The 30-day survival rate after an unwitnessed arrest (n=548) was 0.5%. All survivors in this group were either hypothermic or were victims of near-drowning. CONCLUSIONS: Resuscitation should be withheld in cases of unwitnessed asystole, excluding cases of hypothermia and near-drowning. The prognosis is poor if the FRU response time is over 10 min or the ALS response time is over 10-15 min in bystander-witnessed arrests. The decision of whether or not to attempt resuscitation should not be influenced by the presence of bystander-CPR. Early initiation of ALS should be prioritised in the treatment of out-of-hospital asystole.
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Apoyo Vital Cardíaco Avanzado/estadística & datos numéricos , Reanimación Cardiopulmonar/estadística & datos numéricos , Paro Cardíaco/mortalidad , Inutilidad Médica , Órdenes de Resucitación , Adolescente , Adulto , Apoyo Vital Cardíaco Avanzado/mortalidad , Anciano , Anciano de 80 o más Años , Daño Encefálico Crónico/epidemiología , Daño Encefálico Crónico/etiología , Reanimación Cardiopulmonar/mortalidad , Femenino , Finlandia/epidemiología , Estudios de Seguimiento , Adhesión a Directriz/estadística & datos numéricos , Paro Cardíaco/etiología , Paro Cardíaco/terapia , Mortalidad Hospitalaria , Humanos , Hipotermia/complicaciones , Masculino , Persona de Mediana Edad , Ahogamiento Inminente/complicaciones , Guías de Práctica Clínica como Asunto , Pronóstico , Análisis de Supervivencia , Factores de Tiempo , Resultado del TratamientoAsunto(s)
Apoyo Vital Cardíaco Avanzado/mortalidad , Reanimación Cardiopulmonar/mortalidad , Servicios Médicos de Urgencia/normas , Heridas y Lesiones/mortalidad , Heridas y Lesiones/terapia , Apoyo Vital Cardíaco Avanzado/métodos , Reanimación Cardiopulmonar/métodos , Ensayos Clínicos como Asunto , Servicios Médicos de Urgencia/métodos , Humanos , Evaluación de Procesos y Resultados en Atención de Salud , Estudios RetrospectivosRESUMEN
OBJECTIVE: To evaluate whether the type of on-site care a trauma patient receives affects outcome. SUMMARY BACKGROUND DATA: The controversy regarding the prehospital care of trauma patients between Advanced Life Support (ALS) and Basic Life Support (BLS) is ongoing. Due to this unresolved controversy, as well as historical, cultural, and political factors, there are significant variations with respect to the type of prehospital care available for trauma patients. METHODS: This prospective cohort study compared three types of prehospital trauma care systems: Montreal, where physicians provide ALS (MD-ALS); Toronto, where paramedics provide ALS (PMD-ALS); and Quebec City, where emergency medical technicians provide BLS only (EMT-BLS). The study took advantage of this variation to evaluate the association between the type of on-site care and mortality in patients with major life-threatening injuries. All patients were treated at highly specialized tertiary (level I) trauma hospitals. The main outcome measure was death as a result of injury. Follow-up was to hospital discharge. RESULTS: The overall mortality rates by type of on-site personnel were physicians 35%, paramedics 24%, and EMTs 18%. For patients with major but survivable trauma, the overall mortality rates were physicians 32%, paramedics 28%, and EMTs 26%. The overall mortality rate of patients receiving only BLS at the scene was 18% compared to 29% for patients receiving ALS. For the subgroup of patients with major but survivable injuries, the mortality rates were 30% for ALS and 26% for BLS. The adjusted increased risk for mortality in patients receiving ALS at the scene was 21%. CONCLUSIONS: In urban centers with highly specialized level I trauma centers, there is no benefit in having on-site ALS for the prehospital management of trauma patients.
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Apoyo Vital Cardíaco Avanzado/mortalidad , Reanimación Cardiopulmonar/mortalidad , Servicios Médicos de Urgencia/métodos , Servicios Médicos de Urgencia/estadística & datos numéricos , Heridas y Lesiones/mortalidad , Heridas y Lesiones/terapia , Adulto , Apoyo Vital Cardíaco Avanzado/métodos , Anciano , Técnicos Medios en Salud , Canadá , Reanimación Cardiopulmonar/métodos , Estudios de Cohortes , Auxiliares de Urgencia , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Médicos , Estudios Prospectivos , Centros Traumatológicos , Resultado del Tratamiento , Población UrbanaRESUMEN
Basic life support and rapid defibrillation for ventricular fibrillation or pulseless ventricular tachycardia are the only two interventions that have been shown unequivocally to improve survival after cardiac arrest. Several drugs are advocated to treat cardiac arrest, but despite very encouraging animal data, no drug has been reliably proven to increase survival to hospital discharge after cardiac arrest. This review focuses on recent experimental and clinical data concerning the use of vasopressin, amiodarone, magnesium, and fibrinolytics during advanced life support (ALS). Animal data indicate that, in comparison with epinephrine (adrenaline), vasopressin produces better vital organ blood flow during cardiopulmonary resuscitation (CPR). These apparent advantages have yet to be converted into improved survival in large-scale trials of cardiac arrest in humans. Data from two prospective, randomized trials suggest that amiodarone may improve short-term survival after out-of-hospital ventricular fibrillation cardiac arrest. On the basis of anecdotal data, magnesium is recommended therapy for torsades de pointes and for shock-resistant ventricular fibrillation associated with hypomagnesemia. In the past, CPR has been a contraindication to giving fibrinolytics, but several studies have demonstrated the relative safety of fibrinolysis during and after CPR. Fibrinolytics are likely to be beneficial when cardiac arrest is associated with plaque rupture and fresh coronary thrombus or massive pulmonary embolism. Fibrinolysis may also improve cerebral microcirculatory perfusion once a spontaneous circulation has been restored. A planned, prospective, randomized trial may help to define the role of fibrinolysis during out-of-hospital CPR.