L Svensson

Can we define patients with no chance of survival after out-of-hospital cardiac arrest?

Objective: To evaluate whether subgroups of patients with no chance of survival can be defined among patients with out-of-hospital cardiac arrest. Patients: Patients in the Swedish cardiac arrest registry who fulfilled the following criteria were surveyed: cardiopulmonary resuscitation (CPR) was attempted; the arrest was not crew witnessed; and patients were found in a non-shockable rhythm. Setting: Various ambulance organisations in Sweden. Design: Prospective observational study. Results: Among the 16 712 patients who fulfilled the inclusion criteria, the following factors were independently associated with a lower chance of survival one month after cardiac arrest: no bystander CPR; non-witnessed cardiac arrest; cardiac arrest occurring at home; increasing interval between call for and arrival of the ambulance; and increasing age. When these factors were considered simultaneously two groups with no survivors were defined. In both groups patients were found in a non-shockable rhythm, no bystander CPR was attempted, the arrest was non-witnessed, the arrest took place at home. In one group the interval between call for and arrival of ambulance exceeded 12 minutes. In the other group patients were older than 80 years and the interval between call for and arrival of the ambulance exceeded eight minutes. Conclusion: Among patients who had an out-of-hospital cardiac arrest and were found in a non-shockable rhythm the following factors were associated with a low chance of survival: no bystander CPR, non-witnessed cardiac arrest, the arrest took place at home, increasing interval between call for and arrival of ambulance, and increasing age. When these factors were considered simultaneously, groups with no survivors could be defined. In such groups the ambulance crew may refrain from starting CPR.

Aspects on the increase in bystander CPR in Sweden and its association with outcome

AIMnTo describe changes in the proportion of bystanders performing cardiopulmonary resuscitation (CPR) in out of hospital cardiac arrest (OHCA) in Sweden and to study the impact of bystander CPR on ventricular fibrillation and on survival during various times.nnnPATIENTS AND METHODSnAll patients who suffered from OHCA in Sweden in whom CPR was attempted and who were included in the Swedish cardiac arrest register (SCAR) between 1992 and 2005. Crew witnessed cases were excluded.nnnRESULTSnIn all 34,125 patients were included in the survey. Among witnessed OHCA the proportion of patients receiving bystander CPR increased from 40% in 1992 to 55% in 2005 (p<0.0001). In non-witnessed OHCA the corresponding proportion increased from 22% to 44% (p<0.0001). There was a significant increase in bystander CPR regardless of age, sex and place. The increase was only found when CPR was performed by lay persons (21% in 1992 to 40% in 2005; p<0.0001). Bystander CPR was associated with an increased proportion of patients found in a shockable rhythm and a lower number of shocks to receive return of spontaneous circulation. Bystander CPR was associated with a similar increase in survival early and late in the evaluation.nnnCONCLUSIONnThere was a marked increase in bystander CPR in OHCA, when performed by lay persons, during the last 14 years in Sweden. Bystander CPR was associated with positive effects both on ventricular fibrillation and survival.

Out-of-hospital cardiac arrest: 10 years of progress in research and treatment.

Cardiac disease is the most common cause of mortality in Western countries, with most deaths due to out‐of‐hospital cardiac arrest (OHCA). In Sweden, 5000–10 000 OHCAs occur annually. During the last decade, the time from cardiac arrest to start of cardiopulmonary resuscitation (CPR) and defibrillation has increased, whereas survival has remained unchanged or even increased. Resuscitation of OHCA patients is based on the ‘chain‐of‐survival’ concept, including early (i) access, (ii) CPR, (iii) defibrillation, (iv) advanced cardiac life support and (v) post‐resuscitation care. Regarding early access, agonal breathing, telephone‐guided CPR and the use of ‘track and trigger systems’ to detect deterioration in patients condition prior to an arrest are all important. The use of compression‐only CPR by bystanders as an alternative to standard CPR in OHCA has been debated. Based on recent findings, guidelines recommend telephone‐guided chest compression‐only CPR for untrained rescuers, but trained personnel are still advised to give standard CPR with both compressions and ventilation, and the method of choice for this large group remains unclear and demands for a randomized study. Data have shown the benefit of public access defibrillation for dispatched rescuers (e.g. police and fire fighters) but data are not as strong for the use of automated defibrillators (AEDs) by trained or untrained rescuers. Postresuscitation, use of therapeutic hypothermia, the importance of specific prognostic survival factors in the intensive care unit and the widespread use of percutaneous coronary intervention have all been considered. Despite progress in research and improved treatment regimens, most patients do not survive OHCA. Particular areas of interest for improving survival include (i) identification of high‐risk patients prior to their arrest (e.g. early warning symptoms and genes); (ii) increased use of bystander CPR training (e.g. in schools) and simplified CPR techniques; (iii) better identification of high‐incidence sites and better recruitment of AEDs (via mobile phone solutions?); (iv) improved understanding of the use of therapeutic hypothermia; (v) determining which patients should undergo immediate coronary angiography on hospital admission; and (vi) clarifying the importance of extracorporeal membrane oxygenation during CPR.

Difference in survival after out-of-hospital cardiac arrest between the two largest cities in Sweden: a matter of time?

Background.u2002 Dramatic differences in survival after out‐of‐hospital cardiac arrests (OHCA) reported from different geographical locations require analysis. We therefore compared patients with OHCA in the two largest cities in Sweden with regard to various factors at resuscitation and outcome.

Analysis of initial rhythm, witnessed status and delay to treatment among survivors of out-of-hospital cardiac arrest in Sweden

Background The characteristics of patients who survive out-of-hospital cardiac arrest (OHCA) are incompletely known. The characteristics of survivors of OHCA during a period of 16u2005years in Sweden are described. Methods All the patients included in the Swedish Cardiac Arrest Registry between 1992 and 2007 in whom cardiopulmonary resuscitation was attempted and who were alive after 1u2005month were included in the survey. Results In all, 2432 survivors were registered. Information on initial rhythm at their first ECG recording was missing in 11%. Of the remaining 2165 survivors, 80% had a shockable rhythm and 20% had a non-shockable rhythm. Only a minority with a shockable rhythm among the bystander-witnessed cases were defibrillated within 5u2005min after cardiac arrest. This proportion did not change during the entry period. Among survivors found in a non-shockable rhythm, the majority were bystander-witnessed cases and a few had a delay from cardiac arrest to ambulance arrival of <5u2005min. Of all survivors, more women (27%) than men (18%) were found in a non-shockable rhythm (p<0.0001). During the 16u2005years in which the register was used for this study, the proportion of survivors found in a shockable rhythm did not change significantly. The cerebral performance categories score indicated better cerebral function among patients found in a shockable rhythm than in those found in a non-shockable rhythm. Conclusion Among survivors of OHCA, a substantial proportion was found in a non-shockable rhythm and this occurred more frequently in women than in men. The proportion of survivors found in a shockable rhythm has not changed markedly over time. Survivors found in a shockable rhythm had a better cerebral performance than survivors found in a non-shockable rhythm. The proportion of survivors who were bystander-witnessed and found in a shockable rhythm and defibrillated early is still remarkably low.

Drones may be used to save lives in out of hospital cardiac arrest due to drowning

BACKGROUNDnDrowning leading to out-of-hospital cardiac arrest (OHCA) and death is a major public health concern. Submersion with duration of less than 10min is associated with favorable neurological outcome and nearby bystanders play a considerable role in rescue and resuscitation. Drones can provide a visual overview of an accident scene, their potential as lifesaving tools in drowning has not been evaluated.nnnAIMnThe aim of this simulation study was to evaluate the efficiency of a drone for providing earlier location of a submerged possible drowning victim in comparison with standard procedure.nnnMETHODnThis randomized simulation study used a submerged manikin placed in a shallow (<2m) 100×100-m area at Tylösand beach, Sweden. A search party of 14 surf-lifeguards (control) was compared to a drone transmitting video to a tablet (intervention). Time from start to contact with the manikin was the primary endpoint.nnnRESULTSnTwenty searches were performed in total, 10 for each group. The median time from start to contact with the manikin was 4:34min (IQR 2:56-7:48) for the search party (control) and 0:47min (IQR 0:38-0:58) for the drone-system (intervention) respectively (p<0.001). The median time saved by using the drone was 3:38min (IQR 2:02-6:38).nnnCONCLUSIONnA drone transmitting live video to a tablet is feasible, time saving in comparison to traditional search parties and may be used for providing earlier location of submerged victims at a beach. Drone search can possibly contribute to earlier onset of CPR in drowning victims.

Experiences and outcome from the implementation of a national Swedish automated external defibrillator registry

BACKGROUNDnEarly cardiopulmonary resuscitation (CPR) and defibrillation with an Automated External Defibrillator (AED) increase survival from out-of-hospital cardiac arrest (OHCA). Although international guidelines recommend the use of AED registries to increase AED use, little is known about implementation. The aim of this paper is to describe the development of a national AED registry, to analyse the coverage and barriers to register AEDs.nnnMETHODSnThe Swedish AED Registry (SAEDREG) was initiated in 2009 with the purpose of gathering the data of all public AEDs in Sweden. Data on all AEDs between 2013 and 2016 were included in the study. Additionally, data of non-registered AEDs was collected in one region using a survey to AED owners focusing on AED functionality.nnnRESULTSnThe number of AEDs doubled between 2013-2016. A total of 6703 AEDs (30%) were removed due to unavailability of validation. At the end of 2016, AEDs were most frequently registered in offices and workplaces, 45% (nu202f=u202f7241) followed by shops, 7% (nu202f=u202f1200). In the Gotland region, 218 AEDs, 57% (nu202f=u202f124) were registered in the SAEDREG. Of nu202f=u202f94 Non-registered AED functionality was high, the main reason not to register was unawareness of the SAEDREG, 74.5%. Of those aware of the register but not having registered, 25% stated hard to register as cause.nnnCONCLUSIONSnA national AED registry may gather information of AEDs on a national level. Although numbers have doubled between 2013-2016 in Sweden, a large proportion is still non-registered. More awareness of the registry and easier registration process is needed. General AED functionality seems high regardless of registered or non-registered AEDs. A key area for future research may be to use AED-registers to ascertain effectiveness of AED programs in terms of actual patient outcome.

7 Dispatch of fire-fighters and police officers in out-of-hospital cardiac arrest: a nationwide prospective cohort trial

Aim Dual dispatch of cardiopulmonary resuscitation (CPR) -trained fire-fighters or police officers equipped with automated external defibrillators (AEDs) in addition to emergency medical services (EMS) in out-of-hospital cardiac arrest (OHCA) has in some minor cohort studies been associated with improved survival. The aim of this study was to evaluate the association between dual dispatch and survival in OHCA at a national level. Methods This prospective, cohort study was conducted January 1st, 2012, to December 31st, 2014. OHCA victims in nine Swedish counties covered by dual dispatch and resuscitation by first responders and EMSs were compared with a propensity-matched contemporary control group of OHCA victims in 12 counties where only EMS were dispatched. The primary outcome was survival to 30u2009days. Results 8698 OHCA were included of which 2786 in each group (intervention and control) were matched. The median time from emergency call to arrival of EMSs or first responder was nine minutes in the intervention group vs. ten minutes in the controls (p<0.001). The proportion of patients admitted alive to hospital was 31.4% in the intervention group versus 24.9% in the controls (adjusted OR 1.40, 95%u2009CI 1.24–1.57). Thirty-day survival was 9.5% in the intervention group versus 7.7% in the controls (adjusted OR 1.27, 95%u2009CI 1.05–1.54). Conclusion Dual dispatch of first responders in addition to EMSs in OHCA was associated with a moderate but significant increase in 30u2009day survival. References Myerburg RJ, Fenster J, Velez M, Rosenberg D, Lai S, Kurlansky P, Newton S, Knox M and Castellanos A. Impact of community-wide police car deployment of automated external defibrillators on survival from out-of-hospital cardiac arrest. Circulation. 2002;106:1058–64. PMID: 12196329 Hollenberg J, Riva G, Bohm K, Nordberg P, Larsen R, Herlitz J, Pettersson H, Rosenqvist M and Svensson L. Dual dispatch early defibrillation in out-of-hospital cardiac arrest: the SALSA-pilot dagger. European Heart Journal. 2009;30:1781–1789. doi:10.1093/eurheartj/ehp177. Malta Hansen C, Kragholm K, Pearson DA, Tyson C, Monk L, Myers B, Nelson D, Dupre ME, Fosbol EL, Jollis JG, Strauss B, Anderson ML, McNally B and Granger CB. Association of Bystander and First-Responder Intervention With Survival After Out-of-Hospital Cardiac Arrest in North Carolina, 2010–2013. JAMA: the journal of the American Medical Association. 2015;314:255–64. doi: 10.1001/jama.2015.7938. Conflict of interest None declared. Funding The Swedish Heart–Lung Foundation, the National Board of Health and Welfare, and the Laerdal Foundation for Acute Medicine in Norway.