Out-of-hospital cardiac arrest: prehospital management

doi:10.1016/S0140-6736(18)30316-7

The Lancet

Volume 391, Issue 10124, 10–16 March 2018, Pages 980-988

https://doi.org/10.1016/S0140-6736(18)30316-7 Get rights and content

Summary

Sudden out-of-hospital cardiac arrest is the most time-critical medical emergency. In the second paper of this Series on out-of-hospital cardiac arrest, we considered important issues in the prehospital management of cardiac arrest. Successful resuscitation relies on a strong chain of survival with the community, dispatch centre, ambulance, and hospital working together. Early cardiopulmonary resuscitation and defibrillation has the greatest impact on survival. If the community response does not restart the heart, resuscitation is continued by emergency medical services' staff. However, the best approaches for airway management and the effectiveness of currently used drug treatments are uncertain. Prognostic factors and rules for termination of resuscitation could guide the duration of a resuscitation attempt and decision to transport to hospital. If return of spontaneous circulation is achieved, the focus of treatment shifts to stabilisation, restoration of normal physiological parameters, and transportation to hospital for ongoing care.

Introduction

Out-of-hospital cardiac arrest (OHCA) is a global health problem, with survival varying greatly between communities.1, 2 The chain of survival provides a useful concept to understand differences in prehospital systems of emergency care that result in such variations in survival.³ Survival of patients with OHCA requires a coordinated set of actions, including immediate recognition of cardiac arrest and activation of the emergency response system, early cardiopulmonary resuscitation (CPR), rapid defibrillation, effective advanced life support, and integrated care after cardiac arrest. The chain of survival encompasses the community, emergency medical dispatch, and ambulance and hospital-based services. The medical literature has focused more on hospital and advanced life support treatments than it has on community treatment and issues related to basic life support (figure 1). However, there has been increasing recognition of the importance of basic life support, the role of the community, and the key function of emergency medical dispatch in coordination of bystander CPR and early defibrillation.4, 5

Section snippets

CPR in the community

The earlier CPR is started in OHCA, the more likely it is that the patient will survive.⁶ In a study from Ontario, Canada, the OPALS investigators⁴ concluded that bystander CPR was the most important modifiable factor for survival after OHCA (odds ratio [OR] 2·98, 95% CI 2·07–4·29).

Conventional strategies to improve the frequency of bystander CPR require a concerted public health effort to educate and train the population to perform CPR. These strategies might include mandatory requirements for

Decision to resuscitate

Early descriptions of resuscitation described its application for “hearts that are too good to die”.²⁵ Resuscitation started promptly has the greatest chance of success. If resuscitation efforts are delayed (as often occurs in unwitnessed cardiac arrest or when no bystander CPR is provided), the chances of successful resuscitation are substantially reduced.

International approaches differ in the decision to commence or continue resuscitation. In many but not all settings, resuscitation will be

EMS response and interventions (including pharmacotherapeutic interventions)

Resuscitation efforts by health-care professionals usually follow the Universal Treatment Algorithm.³¹ After confirmation of cardiac arrest by identifying the absence of normal breathing (and absence of a central pulse for those experienced in central pulse palpation), chest compressions (5–6 cm depth, rate 100–120 per min, with minimal interruptions) are delivered while cardiac monitoring is established (figure 4).³² If the initial rhythm is ventricular fibrillation or ventricular tachycardia,

Manual versus mechanical CPR

High-quality CPR is crucial for optimal outcomes after cardiac arrest, yet it is physically demanding and difficult to sustain. Mechanical chest compression devices automate the process and deliver consistent, high-quality chest compressions. Two devices have been evaluated in large, multicentre, prehospital clinical trials that enrolled 12 206 patients with OHCA.⁵¹ The Autopulse device (Zoll Medical, Chelmsford, MA, USA) consists of a load-distributing band encircling the patient's chest and

Transport or termination of resuscitation

There are no absolute rules on the optimal duration of resuscitation. Factors associated with improved outcomes (eg, witnessed arrest, initial shockable rhythm, bystander CPR) or the presence of potentially reversible causes, could guide clinicians to continue with resuscitation efforts for longer. In an analysis of CPR duration, Grunau and colleagues⁵⁴ showed that the elapsed duration at which the probability of survival fell below 1% was 48 min in patients with shockable rhythms and 15 min in

Management priorities

Guidelines from European Resuscitation Council (ERC) and European Society of Intensive Care Medicine (ESICM)⁶⁵ provide information about how to optimise the management of the post-resuscitation syndrome. Post-resuscitation care should start at the location where return of spontaneous circulation is achieved. The most important management priorities in the prehospital setting are circulatory, respiratory, and temperature. In parallel, all efforts should be made to bring the patient to the most

Conclusion

Survival from OHCA remains poor globally. Strengthening of the early links in the chain of survival (ie, cardiac arrest recognition, call for help, bystander CPR, and bystander AED use) have the greatest potential to improve survival. If return of spontaneous circulation occurs, the focus shifts from resuscitation to stabilisation and transfer to a specialist facility.

Search strategy and selection criteria

In this Series paper, we consider the prehospital management of out-of-hospital cardiac arrest, with a focus on the first links in the chain of survival. We searched the Cochrane Library, MEDLINE, and Embase from Jan 1, 2001, to Dec 31, 2017, with the terms “cardiac arrest” or “resuscitation” in combination with “dispatch”, “ambulance”, “pre-hospital”, “emergency medical services”, “defibrillation”, or “cardio-pulmonary resuscitation”. Our search was restricted to English-language publications

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Cited by (149)

Socioeconomic disadvantage and long-term survival duration in out-of-hospital cardiac arrest patients: A population-based cohort study
2024, Resuscitation Plus
Socioeconomic status (SES) is a well-established determinant of cardiovascular health. However, the relationship between SES and clinical outcomes in long-term out-of-hospital cardiac arrest (OHCA) is less well-understood. The Singapore Housing Index (SHI) is a validated building-level SES indicator. We investigated whether SES as measured by SHI is associated with long-term OHCA survival in Singapore.
We conducted an open cohort study with linked data from the Singapore Pan-Asian Resuscitation Outcomes Study (PAROS), and the Singapore Registry of Births and Deaths (SRBD) from 2010 to 2020. We fitted generalized structural equation models, calculating hazard ratios (HRs) using a Weibull model. We constructed Kaplan–Meier survival curves and calculated the predicted marginal probability for each SHI category.
We included 659 cases. In both univariable and multivariable analyses, SHI did not have a significant association with survival. Indirect pathways of SHI mediated through covariates such as Emergency Medical Services (EMS) response time (HR of low-medium, high-medium and high SHI when compared to low SHI: 0.98 (0.88–1.10), 1.01 (0.93–1.11), 1.02 (0.93–1.12) respectively), and age of arrest (HR of low-medium, high-medium and high SHI when compared to low SHI: 1.02 (0.75–1.38), 1.08 (0.84–1.38), 1.18 (0.91–1.54) respectively) had no significant association with OHCA survival. There was no clear trend in the predicted marginal probability of survival among the different SHI categories.
We did not find a significant association between SES and OHCA survival outcomes in residential areas in Singapore. Among other reasons, this could be due to affordable healthcare across different socioeconomic classes.
Overview and future prospects of out-of-hospital cardiac arrest registries in Japan
2024, Resuscitation Plus
Out-of-hospital cardiac arrest (OHCA) is a life-threatening emergency with high mortality. The “chain of survival” is critical to improving patient outcomes. To develop and enhance this chain of survival, measuring and monitoring the resuscitation processes and outcomes are essential for quality assurance. In Japan, several OHCA registries have successfully been implemented at both local and national levels. We aimed to review and summarise the conception, strengths, and challenges of OHCA registries in Japan.
The following representing registries in Japan were reviewed: the All-Japan Utstein registry, the Utstein Osaka Project/the Osaka-CRITICAL study, the SOS-KANTO study, the JAAM-OHCA study, and the SAVE-J II study. The All-Japan Utstein registry, operated by the Fire and Disaster Management Agency of Japan and one of the largest nationwide population-based registries in the world, collects data concerning all patients with OHCA in Japan, excluding in-hospital data. Other research- and hospital-based registries collect detailed out-of-hospital and in-hospital data. The Osaka-CRITICAL study and the SOS-KANTO study are organized at regional levels, and hospitals in the Osaka prefecture and in the Kanto area participate in these registries. The JAAM-OHCA study is managed by the Japanese Association of Acute Medicine and includes 107 hospitals throughout Japan. The Save-J II study focuses on patients with OHCA treated with extracorporeal cardiopulmonary resuscitation.
Each OHCA registry has its own philosophy, strengths, perspectives, and challenges; however, all have been successful in contributing to the improvement of emergency medical service (EMS) systems through the quality improvement process. These registries are expected to be further utilized to enhance EMS systems and improve outcomes for patients with OHCA, while also contributing to the field of resuscitation science.
Association between prehospital time and in-hospital outcomes in out-of-hospital cardiac arrests according to resuscitation outcomes consortium epidemiologic registry
2024, Heart and Lung
For out-of-hospital cardiac arrests (OHCAs), time is of the essence. While the relationship between EMS response time (ERT) and OHCA outcomes is well studied, a more comprehensive assessment of the effects of other intervention time is needed, which is essential to guide clinical practice.
Evaluating how a longer total pre-hospital time (TPT), ERT, advance life support response time (ART) and EMS cardiopulmonary resuscitation time (ECT) increase the mortality rates, unfavorable neurological outcomes, and severe complications at discharge of OHCAs.
31,926 OHCAs from the USA and Canada were identified in Resuscitation Outcomes Consortium Epidemiologic Registry. Twelve adjusted models were used to analyze the relationship between the prehospital time (TPT, ERT, ART and ECT) and three outcomes (in hospital mortality, unfavorable neurological outcomes, and severe complications for surviving OHCAs).
Every 10-min increase in TPT was associated with a 0.14-fold increase in the risk of death (adjusted odds ratio [OR] = 1.14, 95 % confidence interval [CI] = 1.10–1.17) and a 0.13-fold increase of adverse neurological outcomes (OR = 1.13, CI =1.08–1.18). The risk of patient mortality markedly increased with every 5 min increase in ERT (OR = 1.36, CI = 1.26–1.47), ART (OR =1.10, CI = 1.06–1.15), and ECT (OR = 1.46, CI = 1.37–1.56). Adverse neurological outcome was associated with ERT and ECT, and severe complications with ERT and ART.
Prolonged prehospital time, particularly ERT and ECT, are closely associated with in-hospital mortality, unfavorable neurological functions, and severe complications at discharge in OHCAs.
Lower versus higher oxygen targets after resuscitation from out-of-hospital cardiac arrest: A systematic review and meta-analysis of randomized controlled trials
2024, Journal of Critical Care
To update the existing evidence and gain further insight into effects of lower versus higher oxygen targets on the outcomes in patients resuscitated from out-of-hospital cardiac arrest (OHCA).
We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing lower versus higher oxygen targets on the outcomes among adults resuscitated from OHCA. The primary outcome was short-term survival (in hospital or within 30 days). Subgroup analyses were performed according to timing of study interventions.
Seven RCTs with 1454 patients were finally included. The short-term survival did not differ between the two groups with a relative risk (RR) of 0.98 (95% CI, 0.86 to 1.11). There were no significant differences in survival at longest follow-up (RR, 1.01; 95% CI, 0.91 to 1.14), favorable neurological outcome (RR, 1.00; 95% CI, 0.91 to 1.11), length of intensive care unit stay (mean difference, −4.94 h; 95% CI, −14.83 to 4.96 h), or risk of re-arrest (RR, 0.68; 95% CI, 0.21 to 2.19). The quality of evidence ranged from moderate to very low.
Current evidence suggests that targeting a lower or higher oxygen therapy in patients after resuscitation from OHCA results in similar short-term survival and other clinical outcomes.
Impact of the COVID-19 pandemic on Canadian emergency medical system management of out-of-hospital cardiac arrest: A retrospective cohort study
2024, Resuscitation
We sought to describe the impact of the COVID-19 pandemic on the care provided by Canadian emergency medical system (EMS) clinicians to patients suffering out of hospital cardiac arrest (OHCA), and whether any observed changes persisted beyond the initial phase of the pandemic.
We analysed cases of adult, non-traumatic, OHCA from the Canadian Resuscitation Outcome Consortium (CanROC) registry who were treated between January 27th, 2018, and December 31st, 2021. We used adjusted regression models and interrupted time series analysis to examine the impact of the COVID-19 pandemic (January 27th, 2020 – December 31st, 2021)on the care provided to patients with OHCA by EMS clinicians.
There were 12,947 cases of OHCA recorded in the CanROC registry in the pre-COVID-19 period and 17,488 during the COVID-19 period. We observed a reduction in the cumulative number of defibrillations provided by EMS (aRR 0.91, 95% CI 0.89 – 0.93, p < 0.01), a reduction in the odds of attempts at intubation (aOR 0.33, 95% CI 0.31 – 0.34, p < 0.01), higher rates of supraglottic airway use (aOR 1.23, 95% CI 1.16–1.30, p < 0.01), a reduction in vascular access (aOR for intravenous access 0.84, 95% CI 0.79 – 0.89, p < 0.01; aOR for intraosseous access 0.89, 95% CI 0.82 – 0.96, p < 0.01), a reduction in the odds of epinephrine administration (aOR 0.89, 95% CI 0.85 – 0.94, p < 0.01), and higher odds of resuscitation termination on scene (aOR 1.38, 95% CI 1.31 – 1.46, p < 0.01). Delays to initiation of chest compressions (2 min. vs. 3 min., p < 0.01), intubation (16 min. vs. 19 min., p = 0.01), and epinephrine administration (11 min. vs. 13 min., p < 0.01) were observed, whilst supraglottic airways were inserted earlier (11 min. vs. 10 min., p < 0.01).
The COVID-19 pandemic was associated with substantial changes in EMS management of OHCA. EMS leaders should consider these findings to optimise current OHCA management and prepare for future pandemics.
Wolf Creek XVII Part 5: Mobile AEDs
2023, Resuscitation Plus
Millions of out-of-hospital cardiac arrests (OHCA) occur globally each year. Survival after OHCA can be improved with the use of automated external defibrillators (AED). The main strategy for facilitating bystander defibrillation has been fixed-location public access defibrillators (PADs). New strategies of mobile AEDs depart from the model of static PADs and have the potential to address known barriers to early defibrillation and improve outcomes.
Mobile AEDs was one of six focus topics for the Wolf Creek XVII Conference held on June 14–17, 2023, in Ann Arbor, Michigan, USA. Conference invitees included international thought leaders and scientists in the field of cardiac arrest resuscitation from academia and industry. Participants submitted via online survey knowledge gaps, barriers to translation and research priorities for each focus topic. Expert panels used the survey results and their own perspectives and insights to create and present a preliminary unranked list for each category that was debated, revised, and ranked by all attendees to identify the top 5 for each category.
Top knowledge gaps center around understanding the impact of mobile AEDs on OHCA outcomes in various settings and the impact of novel AED technologies. Top barriers to translation include questionable public comfort/acceptance, financial/regulatory constraints, and a lack of centralized accountability. Top research priorities focus on understanding the impact of the mobile AED strategies and technologies on time to defibrillation and OHCA outcomes.
This work informs research agendas, funding priorities and policy decisions around using mobile AEDs to optimize prehospital response to OHCA.

View all citing articles on Scopus

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SeriesOut-of-hospital cardiac arrest: prehospital management

Summary

Introduction

Section snippets

CPR in the community

Decision to resuscitate

EMS response and interventions (including pharmacotherapeutic interventions)

Manual versus mechanical CPR

Transport or termination of resuscitation

Management priorities

Conclusion

Search strategy and selection criteria

Resuscitation

Ann Emerg Med

Ann Emerg Med

Resuscitation

Resuscitation

Ann Emerg Med

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

J Am Coll Cardiol

J Am Coll Cardiol

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Regional variation in out-of-hospital cardiac arrest incidence and outcome

JAMA

Improving survival from sudden cardiac arrest: the “chain of survival” concept: a statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association

Circulation

Modifiable factors associated with survival after out-of-hospital cardiac arrest in the Pan-Asian Resuscitation Outcomes Study

Ann Emerg Med

Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest

N Engl J Med

Bystander efforts and 1-year outcomes in out-of-hospital cardiac arrest

N Engl J Med

Why bystanders decline telephone cardiac resuscitation advice

Acad Emerg Med

Dispatcher-assisted cardiopulmonary resuscitation and survival in cardiac arrest

Circulation

Series
Out-of-hospital cardiac arrest: prehospital management