*Klaudiusz Nadolny1, 2, Jerzy Robert Ladny1, Daniel Slezak3
The influence of emergency medical procedures and event circumstances on the acute effectiveness of resuscitation in out-of-hospital sudden cardiac arrest in adults
Wpływ udzielanych czynności medycznych a skuteczność resuscytacji z pozaszpitalnym nagłym zatrzymaniem krążenia u osób dorosłych
1Department of Emergency Medicine, Medical University of Bialystok, Poland
2University of Strategic Planning in Dabrowa Gornicza, Poland
3Emergency Medicine Workshop, Department of Emergency Medicine, Faculty of Health Sciences, Medical University of Gdansk, Poland
Streszczenie
Wstęp. Nagłe zatrzymanie krążenia jest poważnym zdarzeniem medycznym, które może wystąpić w najmniej oczekiwanym miejscu i czasie. Jest bardzo poważnym problemem medycznym i społecznym.
Cel pracy. Celem pracy była ocena udzielanych świadczeń medycznych u pacjentów, u których wystąpiło pozaszpitalne nagłe zatrzymanie krążenia i skuteczności powrotu parametrów życiowych.
Materiał i metody. Badanie kliniczno-kontrolne przeprowadzono na podstawie dokumentacji medycznej Pogotowia Ratunkowego w Katowicach za 2017 rok. Wyniki zaprezentowano za pomocą wskaźników struktury (liczebności i odsetki) oraz mediany i IQR. Do porównania grup pacjentów „ROSC” oraz „no ROSC” wykorzystano statystyki nieparametryczne: test χ2 Pearsona lub U Manna-Whitneya. Dla wszystkich analiz jako domyślny poziom istotności statycznej przyjęto wartość 0,05.
Wyniki. Do analizy włączono 1713 przypadków pozaszpitalnego NZK. Mężczyźni stanowili 63,68% (N = 1091), a kobiety jedynie 34,5% (N = 591). Kobiety były starsze niż mężczyźni (średnia wieku 69,5 vs 62,9 roku, p = 0,000). Natomiast częściej wykonywano defibrylację u mężczyzn niż u kobiet (p = 0,000). Najczęściej do wystąpienia pozaszpitalnego NZK dochodziło w warunkach domowych (p = 0,000), najczęściej w ciągu dnia (p = 0,000). Wyższy wskaźnik ROSC odnotowano, kiedy świadek udzielał pierwszej pomocy (35,6 vs. 31,41%, p = 0,08). Pacjenci z VF mieli większy wskaźnik ROSC niż z asystolią (56,27 vs. 24,95%, p = 0,000).
Wnioski. ROSC zależy od wykonywanych medycznych czynności ratunkowych na miejscu zdarzenia. Postępowanie zgodnie z aktualną wiedzą medyczną powoduje większy odsetek skuteczności resuscytacji.
Summary
Introduction. Sudden cardiac arrest is a serious medical event that may occur unexpectedly. It is a serious medical and social issue.
Aim. The aim of the study is an analysis of the relationship between the type of medical rescue actions taken and return of spontaneous circulation (ROSC) in adults.
Material and methods. The case-control study was based on the medical documentation of the Rescue Service in Katowice collected in 2017. The results have been presented by means of proportions (sample size and sampling rate), median and IQR. Non-parametric methods (Pearson’s chi-squared test or Mann-Whitney U test) were used to compare the group of ROSC-patients with the group of no-ROSC-patients. The default statistical significance adopted for the purpose of all analyses was 0.05.
Results. The analysis covered 1713 out-of-hospital sudden cardiac arrest (SCA) cases. Male patients constituted 63.68% (N = 1091) of the group, whereas female patients constituted only 34.5% (N = 591) of the cases. Women were older than men (69.5 vs. 62.9; p = 0.000). However, defibrillation was more frequently applied in men than in women (p = 0.000). In a majority of cases, SCA occurred in domestic conditions (p = 0.000) during the day (p = 0.000). ROSC was reported in 591 cases (34.51%). The ROSC rate was higher in cases when witnesses provided first aid to patients (35.6 vs. 31.41%; p = 0.08). The rate was also higher in patients with ventricular fibrillation than in patients with asystole (56.27 vs. 24.95%; p = 0.000).
Conclusions. ROSC depends on the emergency medical procedures actions performed at the place of incident. The ROSC rate in patients is significantly higher when procedures are performed according to the current medical knowledge.
INTRODUCTION
Sudden cardiac arrest (SCA) is a serious medical event that may occur unexpectedly. It is a serious medical and social issue (1). SCA may be caused by various factors (both diseases and traumas) and requires taking immediate rescue actions performed by witnesses as well as by qualified medical emergency teams. In Europe, SCA is diagnosed in 38/100 000 inhabitants per annum (2, 3), whereas in the USA, SCA is diagnosed in 76/100 000 per year (4). Globally, there are numerous registers of out-of-hospital SCA (5, 6).
The definition of SCA is closely related to the notion of sudden cardiac death (SCD). SCD is universally defined as a natural death from a cardiovascular cause presenting loss of consciousness and death within one hour from the occurrence of symptoms (the one-hour period is arbitrary) (7). In spite of the fact that SCA registers have recently indicated an increase in the return of spontaneous circulation (ROSC) rate in Europe and in the world, SCA mortality still remains incredibly high: only 10.6% of SCA patients survive to leave hospital (8).
Witnesses of the incidents play an important role in successful rescue actions. Prompt reaction and resuscitation performed by a third party increase the chances of ROSC (9). Ventricular fibrillation was the first rhythm diagnosed by the emergency medical team in only about 20-25% of cases (10). In such a numerous population that the USA has, shockable rhythms are reported in only 23% of patients, where the survival rate amounts to 22 vs. 8% as far as the non-shockable rhythms are concerned (11, 12). However, when the witness uses an AED (Automated External Defibrillator), the survival rate will reach from 59% up to 79% (13-15).
AIM
The aim of this research was the assessment of the effectiveness of emergency medical procedures performed by emergency medical teams in prehospital care in reference to the ROSC rate in the 2.7-million-population monitored by the Voivodeship Rescue Service (VRS) in Katowice.
MATERIAL AND METHODS
Study design and population
The case-control study was based on the medical documentation of the Emergency Medical Services (EMS) units of Voivodeship Rescue Service (VRS) in Katowice covering 2.7 million inhabitants and collected in 2017 (n = 254 673). The research involved exclusively individuals older than 18 years, with non-hospital SCA. After considering the above inclusion criteria, there were 1713 dispatch order forms (0.67% of all dispatch orders) involved in further research. Consent of the Bioethics Committee was not required.
Data collection and processing
Demographic data (i.e. gender, age, location, time of the day) of the incidents with non-hospital SCA were analyzed. Calls between emergency medical dispatchers and witnesses of the incidents were analyzed as far as first aid instructions and main reporting reason were concerned. Emergency medical teams were divided into two groups, i.e. teams with doctors and teams without doctors. In Poland, the only indicator of the system’s quality is the median of time from team dispatch to team arrival at destination. The median was calculated for both emergency priority codes: C-1 and C-2. Based on the emergency medical procedure forms, the actions of emergency medical teams were verified as far emergency medical procedures (endotracheal intubation, the use of suction pumps, defibrillation, the use of alternatives providing airway patency, the mechanism of cardiac arrest etc.) and ROSC were concerned. The case-control study did not cover actions performed after transfers of patients to intensive care units (ICU). No hospital medical procedures were analyzed.
Statistical analysis
Descriptive statistics involved the calculation of proportions (sample size and sampling rate for non-metric variables), and median, as well as IQR in the case of quantitative variables. Depending on the measurement scale, Pearson’s chi-squared test or Mann-Whitney U test were used to compare the group of ROSC-patients with the group of no-ROSC-patients. The model of logistic regression was applied to estimate the probability of ROSC. The dependent variable was the presence of ROSC (value: 1) or the absence of ROSC (value: 0). STATISTICA 13.1 (StaSoft® Inc.) and IBM® SPSS 24.0 software were used to analyze data. The default statistical significance adopted for the purpose of all analyses was 0.05.
RESULTS
All non-hospital SCA cases involved 1091 male individuals (63.68%) and 591 female individuals (34.5%). There were 31 patients (1.81%) with no gender reported in medical documentation. Moreover, the analyzed cases of non-hospital SCA included 1035 (60.42%) patients aged over 65 years (the age median 66.1 years). Female patients were older than male patients (age mean: 69.5 vs. 62.9; p = 0.000), which was true also for the group of patients aged over 65 years. However, defibrillation was more often performed in men than in women (p = 0.000) (tab. 1). What is more, defibrillation was more frequently performed in patients aged over 65 years than in younger patients (p = 0.011) (tab. 2).
Tab. 1. A comparative analysis of selected variables according to gender
| Variable | Male individuals | Female individuals | P-value* |
| Age > 65 years | 538 (48.2%) | 319 (69.1%) | 0.000 |
| Priority code 1 (urgent) | 991 (90.09%) | 487 (82.4%) | 0.002 |
| Ventilation frequency – ventilation bag | 641 (61.8%) | 335 (55.7%) | 0.017 |
| Defibrillation | 270 (25.3%) | 92 (15.3%) | 0.000 |
| Location (at home) | 704 (68.8%) | 434 (74.5%) | 0.025 |
| Death | 721 (67.2%) | 404 (67.5%) | NS |
*Pearson’s chi-squared test
Tab. 2. A comparative analysis of selected variables according to age
| Variable | Age > 65 years | Age < 65 years | P-value* |
| Defibrillation | 221 (21.35%) | 183 (26.99%) | 0.011 |
| Location (at home) | 713 (68.8%) | 471 (73.82%) | NS |
| Priority code 1 (urgent) | 871 (84.1%) | 611 (90.1%) | 0.017 |
| Total time from dispatch to arrival up to 8 minutes | 414 (40%) | 252 (37.16%) | NS |
| Intubation | 521 (50.33%) | 371 (54.71%) | NS |
*Pearson’s chi-squared test
SCA most frequently occurred during the day (between 07.01 a.m. and 07.00 p.m.) (n = 1062; 61.99%). SCA cases were less frequently reported in the evenings and at night (between 07.01 p.m. and 07.00 a.m.) (n = 651; 38.01%).
Powyżej zamieściliśmy fragment artykułu, do którego możesz uzyskać pełny dostęp.
Mam kod dostępu
- Aby uzyskać płatny dostęp do pełnej treści powyższego artykułu albo wszystkich artykułów (w zależności od wybranej opcji), należy wprowadzić kod.
- Wprowadzając kod, akceptują Państwo treść Regulaminu oraz potwierdzają zapoznanie się z nim.
- Aby kupić kod proszę skorzystać z jednej z poniższych opcji.
Opcja #1
29 zł
Wybieram
- dostęp do tego artykułu
- dostęp na 7 dni
uzyskany kod musi być wprowadzony na stronie artykułu, do którego został wykupiony
Opcja #2
69 zł
Wybieram
- dostęp do tego i pozostałych ponad 7000 artykułów
- dostęp na 30 dni
- najpopularniejsza opcja
Opcja #3
129 zł
Wybieram
- dostęp do tego i pozostałych ponad 7000 artykułów
- dostęp na 90 dni
- oszczędzasz 78 zł
Piśmiennictwo
1. Roger VL, Go As, Lioyd-Jones DM et al.: Executive summary: heart disease and stroke statistics – 2012 update: a report from the American Heart Association. Circulation 2012; 125(1): 188-197.
2. Grasner JT, Herlitz J, Koster RW et al.: Quality management in resuscitation-towards a European cardiac agrest registry (EuReCa). Reuscitation 2011; 82: 989-994.
3. Grasner JT, Bossaert L: Epidemiology and management of cardiac arrest: what registries and revealing. Best Pract Res Clin Anaesthesiol 2013; 27: 293-306.
4. Mozaffarian D, Benjamin EJ, Go AS et al.: Heart disease and stroke statistics – 2015 update: a report from the American Heart Association. Circulation 2015; 131: e29-322.
5. Cebula GM, Osadnik S, Wysocki M et al.: Comparison of the early effects of out-of- hospital resuscitation in selected urban and rural areas in Poland. A preliminary report from the Polish Cardiac Arrest Registry by the Polish Resuscitation Council. Polish Heart Journal 2016; 74: 143-148.
6. Rosell Ortiz F, Mellado Vergel F, Lopez Messa JB et al.: Survival and neurologic outcome after out-of-hospital cardiac arrest. Results of the Andalusian out-of-hospital cardiopulmonary arrest registry. Rev Esp Cardiol 2016; 69: 494-500.
7. Zipes DP, Camm AJ, Borggrefe M et al.: ACC AHA/ESC/2006: Guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. J Am Coll Cardiol 2006; 48(5): e247-346.
8. Centers for Disease Control and Prevention: 2013 Cardiac Arrest Registry to Enhance Survival (CARES) National Summary Report; https://mycares.net/sitepages/uploads/2013/04/CARES_Evaluation_Report_Final.pdf (dostęp z dnia: 20.10.2015).
9. Nadolny K, Gotlib J, Panczyk M et al.: The role oft he witness oft he incident and the role oft he emergency medical dispatcher in out-of-hospital sudden cardiac arrest. Post N Med 2018; XXXI(1): 6:11.
10. Gräsner JT, Lefering R, Koster RW et al.: EuReCa ONE-27 Nations, ONE Europe, ONE Registry prospective one month analysis of out-of-hospital cardiac arrest outcomes in 27 countries in Europe. Resuscitation 2016; 105: 188-195.
11. Kong MH, Fonarow GC, Peterson ED et al.: Systematic review of the incidence of sudden cardiac death in the United States. J Am Coll Cardiol 2011; 57(7): 794-801.
12. Nichol G, Thomas E, Callaway CW et al.: Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA 2008; 300(12): 1423-1431.
13. Weisfeldt ML, Sitlani CM, Ornato JP et al.: Survival after application of automatic external defibrillators before arrival of the emergency medical system: evaluation in the resuscitation outcomes consortium population of 21 milion. J Am Coll Cardiol 2010; 55: 1713-1720.
14. Van Alem AP, Vrenekn RH, De Vos R: Use of automated external defibrillator by first responders in out-of-hospital cardiac arrest: prospective controlled trial. BMJ 2003; 327: 1312.
15. Cacko A, Michalak M, Welk E et al.: Pre-hospital cardiac arrest treated successfully with automated external defibrillator. Polish Heart Journal 2017; 75(6): 618.
16. Gach D, Nowak J, Krzych L: Epidemiology of out-of-hospital cardiac arrest in the Bielsko-Biala district: a 12-month analysis. Kardiol Pol 2016; 74(10): 1180-1187.
17. Wissenberg M, Lippert F, Folke F et al.: Association of national initiatives to improve cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest. JAMA 2013; 310: 1377-1384.
18. Strömsöe A, Svensson L, Axelsson A et al.: Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival. Eur Heart J 2015; 36: 863-871.
19. Nürnberger A, Sterz F, Malzer R et al.: Out of hospital cardiac arrest in Vienna: incidence and outcome. Resuscitation 2013; 84: 42-47.
20. Nadolny K, Gotlib J, Panczyk M et al.: The epidemiology of sudden cardiac arrest in prehospital care in the area of the Silesian voivodship. Wiad Lek 2018; 71(1 cz. II): 193-200.
21. Strömsöe A, Svensson L, Axelsson A et al.: Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival. Eur Heart J 2015; 36: 863-871.
22. Bray J, Stub D, Bernard S: Exploring gender differences and the “oestrogen effect” in an Australian out-of-hospital cardiac arrest population. Resuscitation 2013; 84: 957-963.
23. Hasan O, Al Suwaidi J, Omer A et al.: The influence of female gender on cardiac arrest outcomes: a systematic review of the literature. Curr Med Res Opin 2014; 30: 2169-2178.
24. Do A, Cretikos M, Muscatello D: Epidemiology of out-of-hospital cardiac arrest, NSW, 2012: Time, place and person. Centre for Epidemiology and Evidence, NSW Ministry of Health, Sydney 2013.
25. Bougouin W, Lamhaut L, Marijon E et al.: Characteristics and prognosis of sudden cardiac death in Greater Paris: population-based approach from the Paris Sudden Death Expertise Center (Paris-SDEC). Intensive Care Med 2014; 40: 846-854.
26. Shao F, Li C, Liang L et al.: Outcome of out-of-hospital cardiac arrests in Beijing, China. Resuscitation 2014; 85: 1411-1417.
27. Henry K, Murphy A, Willis D et al.: Out-of-hospital cardiac arrest in Cork, Ireland. Emerg Med J 2013; 30: 496-500.
28. Ballesteros-Pena S, Abecia-Inchaurregui L, Echevarría-Orella E: Factors associated with mortality in out-of-hospital cardiac arrests attended in basic life support units in the Basque Country (Spain). Rev Esp Cardiol (Engl Ed) 2013; 66: 269-274.
29. Rudner R, Jałowiecki P, Wartak M et al.: Ocena wybranych czynników wpływających na wyniki postępowania resuscytacyjnego w pozaszpitalnych zatrzymaniach krążenia. Anest Intens Ter 2005; 3: 174-180.
30. Kłosiewicz T, Skitek-Adamczak I, Zieliński M: Emergency medical system response time does not affect incidence of return of spontaneous circulation after prehospital resuscitation in one million central European agglomeration residents. Polish Heart Journal 2017; 75(3): 240-246.
31. Monsieurs K, Nolan J, Bossaert L et al.: ERC Guidelines 2015 Writing Group. European Resuscitation Council Guidelines for Resuscitation 2015: Section 1. Executive summary. Resuscitation 2015; 95: 1-80.
32. Bagai A, McNally B, Al-Khatib S et al.: Temporal differences in out-of-hospital cardiac arrest incidence and survival. Circulation 2013; 128: 2595-2602.
33. Nagao K: Out-of-hospital cardiac arrest related to cardiac etiology and the weather. Circ J 2013; 77: 1988-1989.
34. Douglas AS, al-Sayer H, Rawles JM: Seasonality of disease in Kuwait. Lancet 1991; 337: 1393-1397.
35. Henry K, Murphy A, Willis D et al.: Out-of-hospital cardiac arrest in Cork, Ireland. Emerg Med J 2013; 30: 496-500.
36. Bougouin W, Lamhaut L, Marijon E et al.: Characteristics and prognosis of sudden cardiac death in Greater Paris: population-based approach from the Paris Sudden Death Expertise Center (Paris-SDEC). Intensive Care Med 2014; 40: 846-854.
37. Perkins GD, Jacobs IG, Nadkarni VM et al.: Cardiac arrest and cardiopulmonary resuscitation outcome reports: update of the Utstein resuscitation registry templates for out-of-hospital cardiac arrest: a statement for healthcare professionals from a task force of the international liaison committee on resuscitation (American Heart Association, European Resuscitation Council, Australian and New Zealand Council on Resuscitation, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, Resuscitation Council of Asia); and the American Heart Association Emergency Cardiovascular Care Committee and the Council on Cardiopulmonary, Critical Care, Perioperative Resuscitation. Resuscitation 2015; 96: 328-340.
38. Keller SP, Halperin HR: Cardiac arrest: the changing incidence of ventricular fibrillation. Curr Treat Options Cardiovasc Med 2015; 17: 392.
39. Hulleman M, Zijlstra JA, Beesems SG et al.: Causes for the declining proportion of ventricular fibrillation in out-of-hospital cardiac arrest. Resuscitation 2015; 96: 23-29.
40. Perkins GD, Travers AH, Considine J et al.: Part 3: Adult basic life support and automated external defibrillation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 2015; 95: e43-70.4.
41. Doerges V, Sauer C, Ocker H et al.: Smaller tidal volumes during cardiopulmonary resuscitation: comparison of adult and paediatric self-inflatable bags with three different ventilatory devices. Resuscitation 1999; 43: 31-37.
42. Ocker H, Wenzel V, Schmucker P et al.: Effectiveness of varius airway management techniques in a bench model simulating a cardiac arrest patient. J Emerg Med 2001; 20: 7-12.
43. Benoit JL, Gerecht RB, Steuerwald MT et al.: Endotracheal intubation versus supraglottic airway placement in out of-hospital cardiac arrest: a meta-analysis. Resuscitation 2015; 93: 20-26.
