Ling Tiah

Comparison of chest compression only and standard cardiopulmonary resuscitation for out-of-hospital cardiac arrest in Singapore

OBJECTIVE Chest compression only cardiopulmonary resuscitation (CC-CPR) without ventilation has been proposed as an alternative to standard cardiopulmonary resuscitation (CPR) for bystanders. However, there has been controversy regarding the relative effectiveness of both of these techniques. We aim to compare the outcomes of cardiac arrest patients in the cardiac arrest and resuscitation epidemiology study who either received CC-CPR, standard CPR or no bystander CPR. METHODS This prospective cohort study involved all out-of-hospital cardiac arrest (OHCA) patients attended to by emergency medical service (EMS) providers in a large urban centre. The data analyses were conducted secondarily on these collected data. The technique of bystander CPR was reported by paramedics who arrived at the scene. RESULTS From 1 October 2001 to 14 October 2004, 2428 patients were enrolled into the study. Of these, 255 were EMS-witnessed arrests and were excluded. 1695 cases did not receive any bystander CPR, 287 had standard CPR and 154 CC-CPR. Patient characteristics were similar in both the standard and CC-CPR groups except for a higher incidence of residential arrests and previous heart disease sufferers in the CC-CPR group. Patients who received standard CPR (odds ratio (OR) 5.4, 95% confidence interval (CI) 2.1-14.0) or CC-CPR (OR 5.0, 95% CI 1.5-16.4) were more likely to survive to discharge than those who had no bystander CPR. There was no significant difference in survival to discharge between those who received CC-CPR and standard CPR (OR 0.9, 95% CI 0.3-3.1). CONCLUSION We found that patients were more likely to survive with any form of bystander CPR than without. This emphasises the importance of chest compressions for OHCA patients, whether with or without ventilation.

A randomised, double-blind, multi-centre trial comparing vasopressin and adrenaline in patients with cardiac arrest presenting to or in the Emergency Department

OBJECTIVE To compare vasopressin and adrenaline in the treatment of patients with cardiac arrest presenting to or in the Emergency Department (ED). DESIGN A randomised, double-blind, multi-centre, parallel-design clinical trial in four adult hospitals. METHOD Eligible cardiac arrest patients (confirmed by the absence of pulse, unresponsiveness and apnea) aged >16 (aged>21 for one hospital) were randomly assigned to intravenous adrenaline (1mg) or vasopressin (40 IU) at ED. Patients with traumatic cardiac arrest or contraindication for cardiopulmonary resuscitation (CPR) were excluded. Patients received additional open label doses of adrenaline as per current guidelines. Primary outcome was survival to hospital discharge (defined as participant discharged alive or survival to 30 days post-arrest). MAIN RESULTS The study recruited 727 participants (adrenaline = 353; vasopressin = 374). Baseline characteristics of the two groups were comparable. Eight participants (2.3%) from adrenaline and 11 (2.9%) from vasopressin group survived to hospital discharge with no significant difference between groups (p = 0.27, RR = 1.72, 95% CI = 0.65-4.51). After adjustment for race, medical history, bystander CPR and prior adrenaline given, more participants survived to hospital admission with vasopressin (22.2%) than with adrenaline (16.7%) (p = 0.05, RR = 1.43, 95% CI = 1.02-2.04). Sub-group analysis suggested improved outcomes for vasopressin in participants with prolonged arrest times. CONCLUSIONS Combination of vasopressin and adrenaline did not improve long term survival but seemed to improve survival to admission in patients with prolonged cardiac arrest. Further studies on the effect of vasopressin combined with therapeutic hypothermia on patients with prolonged cardiac arrest are needed.

Cardiopulmonary resuscitation interruptions with use of a load-distributing band device during emergency department cardiac arrest.

STUDY OBJECTIVE Our primary aim is to measure no-flow time and no-flow ratio before and after an emergency department (ED) switched from manual to a load-distributing band mechanical cardiopulmonary resuscitation (CPR) device. METHODS This was a phased, before-after cohort evaluation at an urban tertiary hospital ED. We collected continuous video and chest compression data with the Physiocontrol CodeStat Suite 7.0 for resuscitations during the period just before and after adoption of load-distributing band CPR. All out-of-hospital, nontraumatic cardiac arrest, adult patients were eligible. From February 2007 to July 2008, there were 26 manual and 41 load-distributing band cases. RESULTS Patients in both phases were comparable in terms of demographics, medical history, witnessed arrest, arrest location, bystander CPR rates, out-of-hospital defibrillation, initial rhythm, and ED defibrillation. The median no-flow time, defined as the sum of all pauses between compressions longer than 1.5 seconds, during the first 5 minutes of resuscitation, was manual CPR 85 seconds (interquartile range [IQR] 45 to 112 seconds) versus load-distributing band 104 seconds (IQR 69 to 151 seconds). The mean no-flow ratio, defined as no-flow time divided by segment length, was manual 0.28 versus load-distributing band 0.40 (difference=-0.12; 95% confidence interval -0.22 to -0.02). However, from 5 to 10 minutes into the resuscitation, median no-flow time was manual 85 seconds (IQR 59 to 151 seconds) versus load-distributing band 52 seconds (IQR 34 to 82 seconds) and mean no-flow ratio manual 0.34 versus load-distributing band 0.21 (difference=0.13; 95% confidence interval 0.02 to 0.24). The average time to apply load-distributing band CPR during this period was 152 seconds. CONCLUSION Application of a load-distributing band in the ED is associated with a higher no-flow ratio than manual CPR in the first 5 minutes of resuscitation. We suggest that attention to team training, rapid application of the device to minimize interruption, and feedback from defibrillator and video recordings may be useful to improve resuscitation team performance.

Improved neurologically intact survival with the use of an automated, load-distributing band chest compression device for cardiac arrest presenting to the emergency department.

IntroductionIt has been unclear if mechanical cardiopulmonary resuscitation (CPR) is a viable alternative to manual CPR. We aimed to compare resuscitation outcomes before and after switching from manual CPR to load-distributing band (LDB) CPR in a multi-center emergency department (ED) trial.MethodsWe conducted a phased, prospective cohort evaluation with intention-to-treat analysis of adults with non-traumatic cardiac arrest. At these two urban EDs, systems were changed from manual CPR to LDB-CPR. Primary outcome was survival to hospital discharge, with secondary outcome measures of return of spontaneous circulation, survival to hospital admission and neurological outcome at discharge.ResultsA total of 1,011 patients were included in the study, with 459 in the manual CPR phase (January 01, 2004, to August 24, 2007) and 552 patients in the LDB-CPR phase (August 16, 2007, to December 31, 2009). In the LDB phase, the LDB device was applied in 454 patients (82.3%). Patients in the manual CPR and LDB-CPR phases were comparable for mean age, gender and ethnicity. The mean duration from collapse to arrival at ED (min) for manual CPR and LDB-CPR phases was 34:03 (SD16:59) and 33:18 (SD14:57) respectively. The rate of survival to hospital discharge tended to be higher in the LDB-CPR phase (LDB 3.3% vs Manual 1.3%; adjusted OR, 1.42; 95% CI, 0.47, 4.29). There were more survivors in LDB group with cerebral performance category 1 (good) (Manual 1 vs LDB 12, P = 0.01). Overall performance category 1 (good) was Manual 1 vs LDB 10, P = 0.06.ConclusionsA resuscitation strategy using LDB-CPR in an ED environment was associated with improved neurologically intact survival on discharge in adults with prolonged, non-traumatic cardiac arrest.

Does Pre-hospital Endotracheal Intubation Improve Survival in Adults with Non-traumatic Out-of-hospital Cardiac Arrest? A Systematic Review

Introduction Endotracheal intubation (ETI) is currently considered superior to supraglottic airway devices (SGA) for survival and other outcomes among adults with non-traumatic out-of-hospital cardiac arrest (OHCA). We aimed to determine if the research supports this conclusion by conducting a systematic review. Methods We searched the MEDLINE, Scopus and CINAHL databases for studies published between January 1, 1980, and 30 April 30, 2013, which compared pre-hospital use of ETI with SGA for outcomes of return of spontaneous circulation (ROSC); survival to hospital admission; survival to hospital discharge; and favorable neurological or functional status. We selected studies using pre-specified criteria. Included studies were independently screened for quality using the Newcastle-Ottawa scale. We did not pool results because of study variability. Study outcomes were extracted and results presented as summed odds ratios with 95% CI. Results We identified five eligible studies: one quasi-randomized controlled trial and four cohort studies, involving 303,348 patients in total. Only three of the five studies reported a higher proportion of ROSC with ETI versus SGA with no difference reported in the remaining two. None found significant differences between ETI and SGA for survival to hospital admission or discharge. One study reported better functional status at discharge for ETI versus SGA. Two studies reported no significant difference for favorable neurological status between ETI and SGA. Conclusion Current evidence does not conclusively support the superiority of ETI over SGA for multiple outcomes among adults with OHCA.

Modifiable Factors Associated With Survival After Out-of-Hospital Cardiac Arrest in the Pan-Asian Resuscitation Outcomes Study

Study objective The study aims to identify modifiable factors associated with improved out‐of‐hospital cardiac arrest survival among communities in the Pan‐Asian Resuscitation Outcomes Study (PAROS) Clinical Research Network: Japan, Singapore, South Korea, Malaysia, Taiwan, Thailand, and the United Arab Emirates (Dubai). Methods This was a prospective, international, multicenter cohort study of out‐of‐hospital cardiac arrest in the Asia‐Pacific. Arrests caused by trauma, patients who were not transported by emergency medical services (EMS), and pediatric out‐of‐hospital cardiac arrest cases (<18 years) were excluded from the analysis. Modifiable out‐of‐hospital factors (bystander cardiopulmonary resuscitation [CPR] and defibrillation, out‐of‐hospital defibrillation, advanced airway, and drug administration) were compared for all out‐of‐hospital cardiac arrest patients presenting to EMS and participating hospitals. The primary outcome measure was survival to hospital discharge or 30 days of hospitalization (if not discharged). We used multilevel mixed‐effects logistic regression models to identify factors independently associated with out‐of‐hospital cardiac arrest survival, accounting for clustering within each community. Results Of 66,780 out‐of‐hospital cardiac arrest cases reported between January 2009 and December 2012, we included 56,765 in the analysis. In the adjusted model, modifiable factors associated with improved out‐of‐hospital cardiac arrest outcomes included bystander CPR (odds ratio [OR] 1.43; 95% confidence interval [CI] 1.31 to 1.55), response time less than or equal to 8 minutes (OR 1.52; 95% CI 1.35 to 1.71), and out‐of‐hospital defibrillation (OR 2.31; 95% CI 1.96 to 2.72). Out‐of‐hospital advanced airway (OR 0.73; 95% CI 0.67 to 0.80) was negatively associated with out‐of‐hospital cardiac arrest survival. Conclusion In the PAROS cohort, bystander CPR, out‐of‐hospital defibrillation, and response time less than or equal to 8 minutes were positively associated with increased out‐of‐hospital cardiac arrest survival, whereas out‐of‐hospital advanced airway was associated with decreased out‐of‐hospital cardiac arrest survival. Developing EMS systems should focus on basic life support interventions in out‐of‐hospital cardiac arrest resuscitation.

Knowledge of Signs and Symptoms of Heart Attack and Stroke among Singapore Residents

Aim. To determine the level of knowledge of signs and symptoms of heart attack and stroke in Singapore resident population, in comparison to the global community. Methods. A population based, random sample of 7,840 household addresses was selected from a validated national sampling frame. Each participant was asked eight questions on signs and symptoms of heart attack and 10 questions on stroke. Results. The response rate was 65.2% with 4,192 respondents. The level of knowledge for preselected, common signs and symptoms of heart attack and stroke was 57.8% and 57.1%, respectively. The respondents scored a mean of 5.0 (SD 2.4) out of 8 for heart attack, while they scored a mean of 6.8 (SD 2.9) out of 10 for stroke. Respondents who were ≥50 years, with lower educational level, and unemployed/retired had the least knowledge about both conditions. The level of knowledge of signs and symptoms of heart attack and stroke in Singapore is comparable to USA and Canada. Conclusion. We found a comparable knowledge of stroke and heart attack signs and symptoms in the community to countries within the same economic, educational, and healthcare strata. However older persons, those with lower educational level and those who are unemployed/retired, require more public health education efforts.

Conversion to shockable rhythms during resuscitation and survival for out-of hospital cardiac arrest.

Background: In out of hospital cardiac arrest (OHCA), the prognostic influence of conversion to shockable rhythms during resuscitation for initially non‐shockable rhythms remains unknown. This study aimed to assess the relationship between initial and subsequent shockable rhythm and post‐arrest survival and neurological outcomes after OHCA. Methodology: This was a retrospective analysis of all OHCA cases collected from the Pan‐Asian Resuscitation Outcomes Study (PAROS) registry in 7 countries in Asia between 2009 and 2012. We included OHCA cases of presumed cardiac etiology, aged 18‐years and above and resuscitation attempted by EMS. We performed multivariate logistic regression analyses to assess the relationship between initial and subsequent shockable rhythm and survival and neurological outcomes. 2‐stage seemingly unrelated bivariate probit models were developed to jointly model the survival and neurological outcomes. We adjusted for the clustering effects of country variance in all models. Results: 40,160 OHCA cases met the inclusion criteria. There were 5356 OHCA cases (13.3%) with initial shockable rhythm and 33,974 (84.7%) with initial non‐shockable rhythm. After adjustment of baseline and prehospital characteristics, OHCA with initial shockable rhythm (odds ratio/OR = 6.10, 95% confidence interval/CI = 5.06–7.34) and subsequent conversion to shockable rhythm (OR = 2.00,95%CI = 1.10–3.65) independently predicted better survival‐to‐hospital‐discharge outcomes. Subsequent shockable rhythm conversion significantly improved survival‐to‐admission, discharge and post‐arrest overall and cerebral performance outcomes in the multivariate logistic regression and 2‐stage analyses. Conclusion: Initial shockable rhythm was the strongest predictor for survival. However, conversion to subsequent shockable rhythm significantly improved post‐arrest survival and neurological outcomes. This study suggests the importance of early resuscitation efforts even for initially non‐shockable rhythms which has prognostic implications and selection of subsequent post‐resuscitation therapy.

Effect of known history of heart disease on survival outcomes after out-of-hospital cardiac arrests

We aimed to investigate the effect of known heart disease on post‐out‐of‐hospital cardiac arrest (OHCA) survival outcomes, and its association with factors influencing survival.

Characteristics and outcomes of young adults who suffered an out-of-hospital cardiac arrest (OHCA) ☆ ☆☆ ★

BACKGROUND There is paucity of data examining the incidence and outcomes of young OHCA adults. The aim of this study is to determine the outcomes and characteristics of young adults who suffered an OHCA and identify factors that are associated with favourable neurologic outcomes. METHODS All EMS-attended OHCA adults between the ages of 16 and 35 years in the Pan-Asian Resuscitation Outcomes Study (PAROS) registry were analysed. The primary outcome was favourable neurologic outcome (Cerebral Performance Category 1 or 2) at hospital discharge or at 30th day post OHCA if not discharged. Regression analysis was performed to identify factors associated with favourable neurologic outcomes. RESULTS 66,780 OHCAs were collected between January 2009 and December 2013; 3244 young OHCAs had resuscitation attempted by emergency medical services (EMS). 56.8% of patients had unwitnessed arrest; 47.9% were of traumatic etiology. 17.2% of patients (95% CI: 15.9-18.5%) had return of spontaneous circulation; 7.8% (95% CI: 6.9-8.8%) survived to one month; 4.6% (95% CI: 4.0-5.4%) survived with favourable neurologic outcomes. Factors associated with favourable neurologic outcomes include witnessed arrest (adjusted RR=2.42, p-value<0.0001), bystander CPR (adjusted RR=1.57, p-value=0.004), first arrest shockable rhythm (adjusted RR=27.24, p-value<0.0001), and cardiac etiology (adjusted RR=3.99, p-value<0.0001). CONCLUSIONS OHCA among young adults are not uncommon. Traumatic OHCA, occurring most frequently in young adults had dismal prognosis. First arrest rhythms of VF/VT/unknown shockable rhythm, cardiac etiology, bystander-witnessed arrest, and bystander CPR were associated with favourable neurological outcomes. The results of the study would be useful for planning preventive and interventional strategies, improving EMS, and guiding future research.