Elsevier

Resuscitation

Volume 72, Issue 3, March 2007, Pages 404-414
Resuscitation

Clinical paper
Utstein style analysis of out-of-hospital cardiac arrest—Bystander CPR and end expired carbon dioxide

https://doi.org/10.1016/j.resuscitation.2006.07.012Get rights and content

Summary

Introduction

The aim of this prospective cohort study was to describe the outcome for patients with out-of-hospital cardiac arrest in Maribor (Slovenia) over a 4 year period using a modified Utstein style, and to investigate elementary knowledge of basic life support among potential bystanders in our community.

Patients and methods

Through the prehospital and the hospital database system we followed up a consecutive group of patients with out-of-hospital cardiac arrest (OHCA) between January 2001 and December 2004. We investigated the effects of various factors on outcome in OHCA, especially partial end-tidal CO2 pressure (petCO2), efficacy of bystander CPR and their elementary knowledge of basic life support (BLS). We also examined motivation among potential bystanders and possible implementation for BLS education in our community.

Results

OHCA was confirmed in 592 patients. Advanced cardiac life support was initiated in 389 patients, of which 277 were of cardiac aetiology. In 287 patients the event was bystanders witnessed and lay-bystander basic life support was performed only in 83 (23%). After treating OHCA by a physician-based prehospital medical team ROSC was obtained in 61%, the ROSC on admission was 50% and the overall survival to discharge was 21%. Initial petCO2 (OR: 22.04; 95%CI: 11.41–42.55), ventricular fibrillation or pulseless ventricular tachycardia as initial rhythm (OR: 2.13; 95%CI: 1.17–4.22), bystander CPR (OR: 2.55; 95%CI: 1.13–5.73), female sex (OR: 3.08; 95%CI: 1.49–6.38) and arrival time (OR: 1.29; 95%CI: 1.11–1.82) were associated with improved ROSC when using multivariate analysis. Using the same method we found that bystander CPR (OR: 5.05; 95%CI: 2.24–11.39), witnessed arrest (OR: 9.98; 95%CI: 2.89–34.44), final petCO2 (OR: 2.37; 95%CI: 1.67–3.37), initial petCO2 (OR: 1.61; 95%CI: 1.28–2.64) and arrival time (OR: 1.39; 95%CI: 1.33–1.60) were associated with improved survival. A questionnaire to potential bystanders has revealed disappointing knowledge about BLS fundamentals. On the other side, there is a welcomed willingness of potential bystanders to take BLS training and to follow dispatchers instructions by telephone on how to perform CPR.

Conclusion

After OHCA in a physician-based prehospital setting in our region, the overall survival to discharge was 21%. The potential bystander in our community is generally poorly educated in performing CPR, but willing to gain knowledge and skills in BLS and to follow dispatchers instructions. Arrival time, witnessed arrest, bystander CPR, initial petCO2 and final petCO2 were significantly positively related with ROSC on admission and with survival. Prehospital data from this and previous studies provide strong support for a petCO2 of 1.33 kPa to be a resuscitation threshold in the field. In our opinion the initial value of petCO2 should be included in every Utstein style analysis.

Introduction

The prognosis among patients who suffer out-of-hospital cardiac arrest (OHCA) is poor. Persistent discouraging low survival rates requires reassessment of current strategies and capacities.1, 2, 3, 4, 5, 6 Improvement in the results of cardiopulmonary resuscitation (CPR) and the subsequent quality of life after cardiac arrest is one of the greatest challenges in emergency medicine.7, 8 Documented prognostic factors are ventricular fibrillation (VF) as the initial rhythm, witnessed cardiac arrest, bystander cardiopulmonary resuscitation, time from collapse to CPR and time to first defibrillation. Human studies have suggested that partial end-tidal CO2 (petCO2) correlates closely with successful resuscitation and predicts the outcome of cardiac arrest reliably.9, 10, 11, 12 Recent studies emphasise bystander CPR as a very important contributory factor in survival from OHCA.13, 14, 15, 16, 17, 18, 19 The aim of this observational study was to evaluate the outcome of OHCA and CPR in the town of Maribor (Slovenia) in the period from January 2001 till December 2004. Our aim was to investigate the effects of a physician-based prehospital emergency unit, initial value of petCO2 and bystander CPR on outcome in OHCA in our community. We investigated the elementary knowledge of basic life support (BLS), and the possible implementation and motivation for education among potential bystanders.

Section snippets

Study design

In this observational prospective study we collected data in the period from January 2001 until December 2004. All emergency calls in this period classified as OHCA dispatched to prehospital emergency unit were included. Data were collected and analysed according to the Utstein criteria and guidelines.20

Study area and population

The study community (town of Maribor with rural area) has a population of circa 200,000 inhabitants spread over an area of approximately 780 km2. The study population was composed of adults over

All cases of OHCA and resuscitation attempts

In evaluation period there were 592 emergency patients without signs of circulation. Finally resuscitation was attempted in a group of 389 patients. The aetiology was presumed cardiac in 277 (72%) cases and non-cardiac in 112 (28%). Restoration of spontaneous circulation (ROSC) was obtained in 61% (237/389) and ROSC on admission to hospital occurred in 50% (195/389). Survival to discharge from hospital occurred in 21% (82/389) (Figure 1).

Location of the incident

The profile according to location of OHCA is shown in

Discussion

The observed incidence of attempted CPR in out-of-hospital cardiac arrest (50 per 100,000 per year) in this study is close to the international average. In the analysis by Herlitz et al.21 the incidence of OHCA in which resuscitated efforts were attempted was similar in a range of 34–63 per 100,000 inhabitants. In European perspective Skogvoll et al.22 reported an annual incidence of attempted CPR of between 33 and 71 per 100,000 inhabitants per year.

As reported in most studies the majority of

Conclusions

After OHCA in a physician-based prehospital EMS in our region, the overall survival to discharge was 21%. Variables associated with ROSC and survival were: arrival time, witnessed arrest, bystander CPR, intial petCO2 and final petCO2. This, and our previous studies, provide strong support for a resuscitation to be attempted considering a petCO2 threshold of 1.33 kPa in the field. We recommend intial petCO2 to be ranked in every Utstein style report to provide better insight into initial

Conflict of interest statement

The authors declare they have no conflicts of interest regarding this study.

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    A Spanish translated version of the summary of this article appears as Appendix in the final online version at 10.1016/j.resuscitation.2006.07.012.

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