Arsene Mullie

Quality and efficiency of bystander CPR

Abstract Incorrectly performed bystander CPR might compromise survival of the cardiac arrest patient. We therefore evaluated the outcome in 3306 out-of-hospital primary cardiac arrests of which 885 received bystander CPR. bystanders performed CPR correctly in 52%, incorrectly in 11%, 31% performed only external chest compressions (ECC) and 6% only mouth-to-mouth ventilation (MMV). The initial ECG in cases without bystander CPR was ventricular fibrillation in 28% (95% confidence interval: 27–30%); 45% (41–50%) and 39% (29–48%), respectively when bystander CPR was performed correctly or incorrectly; 43% (37–49%) when only ECC was applied and 22% (11–33%) when only MMV was practiced. Long term survival, defined as being awake 14 days after CPR, was 16% (13–19%) in patients with correct bystander CPR; 10% (7–14%) and 2% (0–9%), respectively when only ECC or only MMV was performed; 7% (6–8%) when no bystander was involved; 4% (0–8%) when bystander CPR was performed incorrectly. Bystander CPR might have a beneficial effect on survival by maintaining the heart in ventricular fibrillation by ECC. A negative effect of badly performed bystander CPR was not observed compared to cases which had not received bystander CPR.

PREDICTIVE VALUE OF GLASGOW COMA SCORE FOR AWAKENING AFTER OUT-OF-HOSPITAL CARDIAC ARREST

The Glasgow coma score (GCS) during days 1-6 after cardiac arrest was used to predict neurological outcome in 360 resuscitated victims of out-of-hospital cardiac arrest. A predictive rule based on the best GCS of 216 patients resuscitated in 1983-84 (prediction group) was constructed, and its predictive power was tested on 133 patients treated in 1985 (test group). Neurological outcome was correctly predicted 2 days after cardiac arrest in 80% of the prediction group, with a best GCS of 10 or above and 4 or below as cutoff points. For patients with a best GCS of 5-9, prediction of outcome was possible 6 days after cardiac arrest, with a best GCS of 8 during the first 6 days as the single cutoff point. The rule was then validated in the test group: the sensitivity was 96%; the specificity 86%; the negative predictive value 97%; and the positive predictive value 77%. These data suggest that this simple GCS-based rule can be helpful in predicting outcome in patients resuscitated after out-of-hospital cardiac arrest, but confirmation of these data is required in a prospective study in a larger number of patients.

Development of palliative care and legalisation of euthanasia: antagonism or synergy?

Debates about euthanasia often polarise opinion, but Jan Bernheim and colleagues describe how in Belgium the two camps grew up side by side to mutual benefit

Survival after out-of-hospital cardiac arrest in elderly patients

STUDY OBJECTIVES To study whether age of the cardiac arrest patient is related to prognostic factors and survival. STUDY DESIGN Retrospective analysis of a prospective registration of cardiac arrest events in the mobile ICUs of seven participating hospitals. STUDY POPULATION Two thousand seven hundred seventy-six out-of-hospital cardiac arrests in which advanced life support was initiated. Cardiac arrests with a precipitating event requiring specific therapeutic consequences and with specific prognosis were not included in the analysis (eg, trauma, exsanguination, drowning, sudden infant death syndrome). RESULTS Neither resuscitation rate (23%) nor mortality caused by a neurologic reason (9%) was significantly different between age groups. Mortality after CPR of non-neurologic etiology was significantly higher in the elderly patient (younger than 40 years, 16%; 40 to 69 years, 19%; 70 to 79 years, 30%; 80 years or older, 34%; P less than .005) and had a negative effect on survival in resuscitated elderly patients (P less than .05). Elderly patients more frequently had a dependent lifestyle before the arrest (P less than .025), an arrest of cardiac origin (P less than .001), electromechanical dissociation as the type of cardiac arrest (P less than .025), and a shorter duration of advanced life support in unsuccessful resuscitation attempts (r = -.178, P less than .0001). CONCLUSION Because survival two weeks after CPR was not significantly different between age groups, we suggest that decision making in CPR should not be based on age but on factors with better predictive power for outcome and quality of survival.

Early prediction of non-survival for patients suffering cardiac arrest — a word of caution

A total of 6178 persons with out-of-hospital (70%) and inhospital (30%) cardiac arrests from the first of January 1982 until the end of 1989 were reviewed retrospectively with respect to 4 variables, contributing to a score for specific prediction of poor prognosis (cut-off point: >3 points) [11]. These included age, initial ECG, type of respiratory arrest and bystander resuscitation. Presence of ventricular fibrillation, gasping and bystander resuscitation contributes nothing to the score, while presence of asystole or EMD (electromechanical dissociation), apnoea and absence of bystander resuscitation adds one point to it. Of patients scoring 4 or 5 points 44 were awake 14 days post CPR (Class 3). The positive predictive value of the score was 97% (95% CI96–98%) for the out-of-hospital group and 92.2% (95% CI 88–95%) for the in-hospital group. The specificity was respectively 92.3% (95% CI 89–95%) and 94.2% (95% CI 91–96%). Although the score can weigh the likelihood of no success against that of success, we cannot recommend it for decision making as far as abandoning or continuing cardiopulmonary resuscitation efforts.

Questions and Answers on the Belgian Model of Integral End-of-Life Care: Experiment? Prototype?

This article analyses domestic and foreign reactions to a 2008 report in the British Medical Journal on the complementary and, as argued, synergistic relationship between palliative care and euthanasia in Belgium. The earliest initiators of palliative care in Belgium in the late 1970s held the view that access to proper palliative care was a precondition for euthanasia to be acceptable and that euthanasia and palliative care could, and should, develop together. Advocates of euthanasia including author Jan Bernheim, independent from but together with British expatriates, were among the founders of what was probably the first palliative care service in Europe outside of the United Kingdom. In what has become known as the Belgian model of integral end-of-life care, euthanasia is an available option, also at the end of a palliative care pathway. This approach became the majority view among the wider Belgian public, palliative care workers, other health professionals, and legislators. The legal regulation of euthanasia in 2002 was preceded and followed by a considerable expansion of palliative care services. It is argued that this synergistic development was made possible by public confidence in the health care system and widespread progressive social attitudes that gave rise to a high level of community support for both palliative care and euthanasia. The Belgian model of so-called integral end-of-life care is continuing to evolve, with constant scrutiny of practice and improvements to procedures. It still exhibits several imperfections, for which some solutions are being developed. This article analyses this model by way of answers to a series of questions posed by Journal of Bioethical Inquiry consulting editor Michael Ashby to the Belgian authors.

Pre-CPR conditions and the final outcome of CPR

Outcome of cardiac arrest (CA) is very much influenced by pre-CPR conditions. To assess the importance of these pre-CPR factors, an analysis of the Belgian CPCR registry was made according to some pre-CPR conditions. In this registry, several variables related to pre-arrest, arrest, CPR and post CPR period have been recorded in 4548 patients. The pre-CPR conditions studied were: age, witnessed event or not, pre-arrest health state, underlying disease, site of cardiac arrest, type of respiratory arrest and type of cardiac arrest. Age did not influence outcome significantly. The importance of witnessing is very significant. Severe pre-arrest disability reduces chances on long-term survival (LTS) to half and overall health status longterm survivors is clearly less. Intoxication and metabolic origin of CA have good prognosis (LTS, 21%). Trauma/exsanguination, drowning, SIDS and sepsis have bad prognosis (LTS, 1-3%). Cardiac (LTS, 12%) and respiratory (LTS, 14%) origin have similar outcome, although significant difference exists in occurrence of cerebral failure, suggesting that post-ischemic encephalopathy is more severe in respiratory than in cardiac origin. The most frequent site of CA, the home of the patient, has poor outcome results (LTS, 5%). Gasping is significantly related to successful outcome. In the out-of-hospital setting the type of CA was 25% VF (LTS, 77%), 65% asystole (LTS, 4%) and 10% EMD (LTS, 3%). Outcome of the subgroup out-of-hospital, witnessed, VF is comparable to other reports. This sub-group seems to us the most appropriate for clinical trials.

Predictors of electromechanical dissociation during cardiac arrest

ECG patterns observed during cardiac arrest were analyzed in 261 comatose cardiac arrest survivors. Forty-seven patients (18%) exhibited electromechanical dissociation (EMD) at some point before restoration of stable spontaneous circulation. These patients had a higher mortality (P = .05) and a lower rate of cerebral recovery (P = .01) during the one-year follow-up than study patients who did not exhibit EMD. Patients who developed EMD subsequent to defibrillation had better outcome than patients presenting with EMD. Multivariate analysis revealed that age more than 70 years old (P = .007), pulmonary disease (P less than .001), diabetes (P = .013, in-hospital arrests only), and prearrest hypoxemia (P = .013, outside-hospital arrests only) were independently predictive of the occurrence of EMD. Although the generalizability of these findings is limited, they may offer new clues to the pathophysiology of EMD.

Relevance and significance of pre-CPR conditions in cardio-pulmonary-cerebral resuscitation. A graphic analysis by means of spectramap

The effects of pre-arrest conditions on success rates of CPCR have been studied in 4501 circulatory arrests that have been recorded by the Belgian CPCR-Registry from 1983 to 1987. A graphical technique called Spectramap has been used for the simultaneous perception of clinical relevance and statistical significance. The success of CPCR is determined to a large extent by pre-arrest conditions. Arrests occurring inside hospitals possess a far better prognosis than those observed outside. (Overall success rate inside hospitals is 18% vs. 7% outside). Site of arrest, time to call, time to CPR, and bystander intervention appear to be relevant and significant conditions outside the hospital. Age, underlying disease and degree of disability are shown to be relevant and significant inside hospitals. The Belgian CPCR-Registry, combined with Spectramap, also allows assessment of the efficiency of emergency services and the efficacy of life supporting treatments. This article describes the graphical method of Spectramap and its application to the Belgian CPCR-Registry.

Should semiautomatic defibrillators be used by emergency medical technicians in Belgium

SummaryEarly external defibrillation is the single most effective intervention in patients with out-of-hospital cardiac arrest. Literature data indicate that instructing emergency medical technicians (EMTs) to use defibrillators is beneficial, provided the local emergency medical system is well organized.We tried to estimate the potential benefit of early defibrillation in some centres in Belgium by retrospectively analyzing the data from the Belgian Cardio-Pulmonary-Cerebral Resuscitation Registry collected between 1983 and 1987 in Belgian centres with a Mobile Intensive Care Unit (MICU).The data show that 2310 out of 3371 patients (69%) were first attended by the EMTs; on subsequent arrival of the MICU-teams, 584 of these 2310 patients i.e. 17% of the whole study population, presented with ventricular fibrillation. Analysis of estimated time factors in these 2310 patients revealed that the median time interval between collapse and start of resuscitation by EMTs was 8 min; the median time interval betwee...