Erika Frischknecht Christensen

Association of national initiatives to improve cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest

IMPORTANCE Out-of-hospital cardiac arrest is a major health problem associated with poor outcomes. Early recognition and intervention are critical for patient survival. Bystander cardiopulmonary resuscitation (CPR) is one factor among many associated with improved survival. OBJECTIVE To examine temporal changes in bystander resuscitation attempts and survival during a 10-year period in which several national initiatives were taken to increase rates of bystander resuscitation and improve advanced care. DESIGN, SETTING, AND PARTICIPANTS Patients with out-of-hospital cardiac arrest for which resuscitation was attempted were identified between 2001 and 2010 in the nationwide Danish Cardiac Arrest Registry. Of 29,111 patients with cardiac arrest, we excluded those with presumed noncardiac cause of arrest (n = 7390) and those with cardiac arrests witnessed by emergency medical services personnel (n = 2253), leaving a study population of 19,468 patients. MAIN OUTCOMES AND MEASURES Temporal trends in bystander CPR, bystander defibrillation, 30-day survival, and 1-year survival. RESULTS The median age of patients was 72 years; 67.4% were men. Bystander CPR increased significantly during the study period, from 21.1% (95% CI, 18.8%-23.4%) in 2001 to 44.9% (95% CI, 42.6%-47.1%) in 2010 (P < .001), whereas use of defibrillation by bystanders remained low (1.1% [95% CI, 0.6%-1.9%] in 2001 to 2.2% [95% CI, 1.5%-2.9%] in 2010; P = .003). More patients achieved survival on hospital arrival (7.9% [95% CI, 6.4%-9.5%] in 2001 to 21.8% [95% CI, 19.8%-23.8%] in 2010; P < .001). Also, 30-day survival improved (3.5% [95% CI, 2.5%-4.5%] in 2001 to 10.8% [95% CI, 9.4%-12.2%] in 2010; P < .001), as did 1-year survival (2.9% [95% CI, 2.0%-3.9%] in 2001 to 10.2% [95% CI, 8.9%-11.6%] in 2010; P < .001). Despite a decrease in the incidence of out-of-hospital cardiac arrests during the study period (40.4 to 34.4 per 100,000 persons in 2001 and 2010, respectively; P = .002), the number of survivors per 100,000 persons increased significantly (P < .001). For the entire study period, bystander CPR was positively associated with 30-day survival, regardless of witnessed status (30-day survival for nonwitnessed cardiac arrest, 4.3% [95% CI, 3.4%-5.2%] with bystander CPR and 1.0% [95% CI, 0.8%-1.3%] without; odds ratio, 4.38 [95% CI, 3.17-6.06]). For witnessed arrest the corresponding values were 19.4% (95% CI, 18.1%-20.7%) vs 6.1% (95% CI, 5.4%-6.7%); odds ratio, 3.74 (95% CI, 3.26-4.28). CONCLUSIONS AND RELEVANCE In Denmark between 2001 and 2010, an increase in survival following out-of-hospital cardiac arrest was significantly associated with a concomitant increase in bystander CPR. Because of the co-occurrence of other related initiatives, a causal relationship remains uncertain.

Return to Work in Out-of-Hospital Cardiac Arrest Survivors: A Nationwide Register-Based Follow-Up Study

Background— Data on long-term function of out-of-hospital cardiac arrest survivors are sparse. We examined return to work as a proxy of preserved function without major neurologic deficits in survivors. Methods and Results— In Denmark, out-of-hospital cardiac arrests have been systematically reported to the Danish Cardiac Arrest Register since 2001. During 2001–2011, we identified 4354 patients employed before arrest among 12 332 working-age patients (18–65 years), of whom 796 survived to day 30. Among 796 survivors (median age, 53 years [quartile 1–3, 46–59 years]; 81.5% men), 610 (76.6%) returned to work in a median time of 4 months [quartile 1–3, 1–19 months], with a median time of 3 years spent back at work. A total of 74.6% (N=455) remained employed without using sick leave during the first 6 months after returning to work. This latter proportion of survivors returning to work increased over time (66.1% in 2001–2005 versus 78.1% in 2006–2011; P=0.002). In multivariable Cox regression analysis, factors associated with return to work with ≥6 months of sustainable employment were as follows: (1) arrest during 2006–2011 versus 2001–2005, hazard ratio (HR), 1.38 (95% CI, 1.05–1.82); (2) male sex, HR, 1.48 (95% CI, 1.06–2.07); (3) age of 18 to 49 versus 50 to 65 years, HR, 1.32 (95% CI, 1.02–1.68); (4) bystander-witnessed arrest, HR, 1.79 (95% CI, 1.17–2.76); and (5) bystander cardiopulmonary resuscitation, HR, 1.38 (95% CI, 1.02–1.87). Conclusions— Of 30-day survivors employed before arrest, 76.6% returned to work. The percentage of survivors returning to work increased significantly, along with improved survival during 2001–2011, suggesting an increase in the proportion of survivors with preserved function over time.Background— Data on long-term function of out-of-hospital cardiac arrest survivors are sparse. We examined return to work as a proxy of preserved function without major neurologic deficits in survivors. Methods and Results— In Denmark, out-of-hospital cardiac arrests have been systematically reported to the Danish Cardiac Arrest Register since 2001. During 2001–2011, we identified 4354 patients employed before arrest among 12 332 working-age patients (18–65 years), of whom 796 survived to day 30. Among 796 survivors (median age, 53 years [quartile 1–3, 46–59 years]; 81.5% men), 610 (76.6%) returned to work in a median time of 4 months [quartile 1–3, 1–19 months], with a median time of 3 years spent back at work. A total of 74.6% (N=455) remained employed without using sick leave during the first 6 months after returning to work. This latter proportion of survivors returning to work increased over time (66.1% in 2001–2005 versus 78.1% in 2006–2011; P =0.002). In multivariable Cox regression analysis, factors associated with return to work with ≥6 months of sustainable employment were as follows: (1) arrest during 2006–2011 versus 2001–2005, hazard ratio (HR), 1.38 (95% CI, 1.05–1.82); (2) male sex, HR, 1.48 (95% CI, 1.06–2.07); (3) age of 18 to 49 versus 50 to 65 years, HR, 1.32 (95% CI, 1.02–1.68); (4) bystander-witnessed arrest, HR, 1.79 (95% CI, 1.17–2.76); and (5) bystander cardiopulmonary resuscitation, HR, 1.38 (95% CI, 1.02–1.87). Conclusions— Of 30-day survivors employed before arrest, 76.6% returned to work. The percentage of survivors returning to work increased significantly, along with improved survival during 2001–2011, suggesting an increase in the proportion of survivors with preserved function over time. # CLINICAL PERSPECTIVE {#article-title-36}

Recommended guidelines for reporting on emergency medical dispatch when conducting research in emergency medicine: The Utstein style☆

OBJECTIVES To establish a uniform framework describing the system and organisation of emergency medical response centres and the process of emergency medical dispatching (EMD) when reporting results from studies in emergency medicine and prehospital care. DESIGN AND RESULTS In September 2005 a task force of 22 experts from 12 countries met in Stavanger; Norway at the Utstein Abbey to review data and establish a common terminology for medical dispatch centres including core and optional data to be used for health monitoring, benchmarking and future research.

Continuous blockade of the lumbar plexus after knee surgery: a comparison of the plasma concentrations and analgesic effect of bupivacaine 0.250% and 0.125%.

In 20 patients a continuous block of the lumbar plexus was administered after knee joint surgery, and the analgesic effect of two different concentrations of bupivacaine was compared. The same volume of bupivacaine was given to both groups of patients: a bolus dose of 0.4 ml/kg, 0.5% or 0.25%, followed by infusion of 0.14 ml/kg/h, 0.25% or 0.125%, respectively, via a catheter placed in the neurovascular fascial sheath of the femoral nerve according to the “3‐in‐1 block” technique. The median morphine consumption during the first 16 h postoperatively was 6.0 mg when bupivacaine 0.5/0.25% was used and 9.5 mg when 0.25/0.125% was used. This difference is not significant. The visual analogue pain scores were also similar in the two groups (P > 0.05). All plasma concentrations were below 4 μg/ml, the highest concentration measured being 3.6 μg/ml. It is concluded that when used for a continuous block of the lumbar plexus after knee‐joint surgery, bupivacaine in a concentration of 0.125% offers the same pain relief as a concentration of 0.25%, and the risk of toxic reactions is reduced.

A systematic review of controlled studies: do physicians increase survival with prehospital treatment?

BackgroundThe scientific evidence of a beneficial effect of physicians in prehospital treatment is scarce. The objective of this systematic review of controlled studies was to examine whether physicians, as opposed to paramedical personnel, increase patient survival in prehospital treatment and if so, to identify the patient groups that gain benefit.MethodsA systematic review of studies published in the databases PubMed, EMBASE and Cochrane from January 1, 1990 to November 24, 2008. Controlled studies comparing patient survival with prehospital physician treatment vs. treatment by paramedical personnel in trauma patients or patients with any acute illness were included.ResultsWe identified 1.359 studies of which 26 met our inclusion criteria. In nine of 19 studies including between 25 and 14.702 trauma patients in the intervention group, physician treatment increased survival compared to paramedical treatment. In four of five studies including between nine and 85 patients with out of hospital cardiac arrest, physician treatment increased survival. Only two studies including 211 and 2.869 patients examined unselected, broader patient groups. Overall, they demonstrated no survival difference between physician and paramedical treatment but one found increased survival with physician treatment in subgroups of patients with acute myocardial infarction and respiratory diseases.ConclusionOur systematic review revealed only few controlled studies of variable quality and strength examining survival with prehospital physician treatment. Increased survival with physician treatment was found in trauma and, based on more limited evidence, cardiac arrest. Indications of increased survival were found in respiratory diseases and acute myocardial infarction. Many conditions seen in the prehospital setting remain unexamined.

Prehospital Troponin T Testing in the Diagnosis and Triage of Patients With Suspected Acute Myocardial Infarction

Prehospital electrocardiographic (ECG) diagnosis has improved triage and outcome in patients with acute ST-elevation myocardial infarction. However, many patients with acute myocardial infarction (AMI) present with equivocal ECG patterns making prehospital ECG diagnosis difficult. We aimed to investigate the feasibility and ability of prehospital troponin T (TnT) testing to improve diagnosis in patients with chest pain transported by ambulance. From June 2008 through September 2009, patients from the central Denmark region with suspected AMI and transported by ambulance were eligible for prehospital TnT testing with a qualitative point-of-care test (cutpoint 0.10 ng/ml). Quantitative TnT was measured at hospital arrival and after 8 and 24 hours (cutpoint 0.03 ng/ml). A prehospital electrocardiogram was recorded in all patients. Prehospital TnT testing was attempted in 958 patients with a 97% success rate. In 258 patients, in-hospital TnT values were increased (≥0.03 ng/ml) during admission. The prehospital test identified 26% and the first in-hospital test detected 81% of patients with increased TnT measurements during admission. A diagnosis of AMI was established in 208 of 258 patients with increased TnT. The prehospital test identified 30% of these patients, whereas the first in-hospital test detected 79%. Median times from symptom onset to blood sampling were 83 minutes (46 to 167) for the prehospital sample and 165 minutes (110 to 276) for the admission sample. In conclusion, prehospital TnT testing is feasible with a high success rate. This study indicates that prehospital implementation of quantitative tests, with lower detection limits, could identify most patients with AMI irrespective of ECG changes.

Prehospital tracheal intubation in severely injured patients: a Danish observational study

The value of advanced prehospital life support for patients with severe trauma—for example, endotracheal intubation by ambulance staff—is unclear. Only one randomised controlled trial was found among 2034 papers in a Cochrane review, concluding that advanced trauma life support by ambulance crews should be initiated only as part of rigorously conducted trials.1 A critical review also failed to show benefit and reported success rates for endotracheal intubation from 57% to 92%.2 The review questioned whether prehospital staff could master the required skills. These reviews focus on paramedic based systems. The helicopter emergency medical services in London is staffed by doctors; the service studied 486 trauma patients …

Reporting of data from out-of-hospital cardiac arrest has to involve emergency medical dispatching—Taking the recommendations on reporting OHCA the Utstein style a step further ☆

OBJECTIVES As a part of the chain of survival, the emergency medical communication centre (EMCC) and the emergency medical dispatcher (EMD) has an important role in early identification of out-of-hospital cardiac arrests (OHCA). The EMD may provide instructions to the caller and thereby initiate cardiopulmonary resuscitation in a substantial number of subjects and thus contribute to increased survival. The EMCC provides a response with first responders, ambulances, physician manned units and potentially other health care providers. EMCC in many cases initiates the communication with experts in the referral hospital and provide added value to the post resuscitation care by providing advanced transport, logistics and follow up. In research there is a growing focus on the EMCC/EMDs impact on survival in OHCA. The lack of standards in reporting results from medical dispatching is an obstacle for thorough evaluation of results in this area and comparison of data. The objective for this paper is to introduce a framework for uniform reporting of the dispatching process for quality improvement, collecting and reporting data and exchanging information regarding OHCA.

Drug and alcohol use among patients admitted to a Danish trauma centre: a prospective study from a regional trauma centre in Scandinavia

Objectives: The incidence of drug and alcohol use is unknown among Danish trauma patients, and has not been thoroughly investigated in Europe. Methods: Patients admitted to the regional trauma centre in Aarhus, Denmark, were prospectively screened by blood and urine tests for the presence of alcohol, and legal and illicit drugs. The correlation with the Injury Severity Score, hospitalization time, and mortality after drug or alcohol intake was investigated. Results: A quarter of all patients admitted in 1999 and 2000 had an alcohol level exceeding the national legal driving limit of 50 mg/dl, and one or more drugs were found in one in five patients. The presence of any drug or alcohol correlated positively with the Injury Severity Score, whereas alcohol level, hospitalization time, and mortality did not correlate. Conclusion: The rate of trauma patients with a blood serum level of alcohol greater than 100 mg/dl was similar to a previous European study and to US studies. The prevalence of drugs was less, and benzodiazepines were the most used group of drugs in our study. The routine screening of Danish trauma patients in order to implement preventative measures may be beneficial.

Out-of-hospital cardiac arrests in children and adolescents: Incidences, outcomes, and household socioeconomic status

BACKGROUND There is insufficient knowledge of out-of-hospital cardiac arrest (OHCA) in the very young. OBJECTIVES This nationwide study sought to examine age-stratified OHCA characteristics and the role of parental socioeconomic differences and its contribution to mortality in the young population. METHODS All OHCA patients in Denmark, ≤21 years of age, were identified from 2001 to 2010. The population was divided into infants (<1 year); pre-school children (1-5 years); school children (6-15 years); and high school adolescents/young adults (16-21 years). Multivariate logistic regression analyses were used to investigate associations between pre-hospital factors and study endpoints: return of spontaneous circulation and survival. RESULTS A total of 459 individuals were included. Overall incidence of OHCA was 3.3 per 100,000 inhabitants per year. The incidence rates for infants, pre-school children, school children and high school adolescents were 11.5, 3.5, 1.3 and 5.3 per 100,000 inhabitants. Overall bystander CPR rate was 48.8%, and for age groups: 55.4%, 41.2%, 44.9% and 63.0%, respectively. Overall 30-day survival rate was 8.1%, and for age groups: 1.4%, 4.5%, 16.1% and 9.3%, respectively. High parental education was associated with improved survival after OHCA (OR 3.48, CI 1.27-9.41). Significant crude difference in survival (OR 3.18, CI 1.22-8.34) between high household incomes vs. low household incomes was found. CONCLUSION OHCA incidences and survival rates varied significantly between age groups. High parental education was found to be associated with improved survival after OHCA.