Elsevier

Resuscitation

Volume 144, November 2019, Pages 157-165
Resuscitation

Clinical paper
One year experience with fast track algorithm in patients with refractory out-of-hospital cardiac arrest

https://doi.org/10.1016/j.resuscitation.2019.07.035Get rights and content

Abstract

Background

Overall prognosis in patients with out-of-hospital cardiac arrest (OHCA) remains poor, especially when return of spontaneous circulation (ROSC) cannot be achieved at the scene. It is unclear if rapid transport to the hospital with ongoing cardiopulmonary resuscitation (CPR) improves outcome in patients with refractory OHCA (rOHCA). The aim of this study was to evaluate the effect of a novel fast track algorithm (FTA) in patients with rOHCA.

Methods

This prospective single-center study analysed outcome in rOHCA patients treated with FTA. Historical patients before FTA-implementation served as controls. rOHCA was defined as: persistent shockable rhythm after three shocks and 300 mg of amiodarone or persistent non-shockable rhythm and continuous CPR for 10 min without ROSC after exclusion of treatable arrest causes.

Results

110 consecutive patients with rOHCA (mean age 56 ± 14 years) were included. 40 patients (36%) were treated with FTA, 70 patients (64%) served as historical controls. Pre-hospital time was significantly shorter after FTA implementation (69 ± 18 vs. 79 ± 24 min, p = 0.02). Favourable neurological outcome (defined as cerebral performance categories Score 1 or 2) was significantly more frequent in FTA patients (27.5% vs. 11.4%, p = 0.038). FTA-implementation showed a trend towards improved mortality (70.0% vs. 82.9%, p = 0.151). Extracorporeal Life Support was similar between the two groups.

Conclusion

Our study suggests that a rapid transport algorithm with ongoing CPR is feasible, improves neurological outcome and may improve survival in carefully selected patients with rOHCA.

Introduction

Despite all efforts, mortality in patients with out-of-hospital cardiac arrest (OHCA) has remained almost unchanged at >90% for the last decades.1 Cardiac etiology is presumed to be the most common cause of OHCA,2, 3 with acute myocardial infarction (AMI) seen in 35% to 80% of patients.4, 5, 6, 7 Percutaneous coronary intervention (PCI) has been demonstrated to improve outcome in OHCA patients.8, 9 However, patients in which ROSC cannot be established often do not reach the hospital and die at the scene. It is currently the subject of discussion whether transport to the hospital with ongoing cardiopulmonary resuscitation (CPR) improves survival and neurological outcome in patients with refractory OHCA (rOHCA).10 Current resuscitation guidelines recommend considering transport with ongoing CPR if an immediate access to a catheterization laboratory is available with teams experienced in mechanical and/or haemodynamic support and rescue PCI with ongoing CPR.11 However, precise criteria for patient selection are lacking and the optimal time point for transportation is still unclear. On the other hand, there is growing evidence that carefully selected patients12, 13, 14, 15 can benefit from an early transport to the hospital with ongoing CPR for further treatment.16, 17, 18 The hypothesis of the study was that a structured algorithm for rapid pre-hospital management by the emergency medical service (EMS) improves outcome in rOHCA patients.

Section snippets

Patients and methods

The EMS in Cologne is run by the Fire Department of Cologne and supported by partnering aid organizations. They cover an area of approximately 405 km2, servicing a population of more than 1 million. In case of resuscitation, telephone CPR is initiated by an EMS dispatcher. As a physician-based system, both an emergency-physician (EP) and a paramedic team are called to every OHCA.

In this single-centre observational study, outcome of patients with rOHCA treated with FTA and feasibility of the FTA

Baseline characteristics and pre-hospital time

One hundred and twenty consecutive patients with rOHCA were admitted to the Department of Cardiology during the study period. Ten patients were excluded from the analysis for various reasons (Fig. 1). One hundred and ten patients with a mean age of 56 ± 14 years were included into the study. Of the 110 study subjects, 70 (64%) reached the hospital before and 40 patients (36%) after FTA implementation. Nearly 60% of the all patients presented with definite cardiac cause of OHCA. AMI was the most

Discussion

In this study, we investigated the feasibility and efficacy of a modified resuscitation algorithm on outcome in patients with rOHCA. The main finding was a significant decrease in pre-hospital treatment time as well as an increase in proportion of patients with favourable neurologic outcome after FTA implementation compared to the historical control group.

The pre-hospital selection of patients who could benefit from transport with ongoing CPR plays a key role and strongly influenced the results

Limitations

The present study has several limitations: (I) Our study was performed in cooperation with a high-performance EMS and a tertiary university hospital with a novel algorithm for treating patients with rOHCA. Therefore, it is not clear, whether our results are transferable to other EMS or hospital sectors. (II) The implementation of FTA resulted in bypassing of nearby clinics and we have not assessed individual time loss for each patient. As this potential bias would only affect the outcome of the

Conclusion

Our study shows that the implementation of a novel modified resuscitation algorithm (into a physician-based EMS is feasible and significantly reduces pre-hospital time in rOHCA patients. Furthermore, FTA significantly improved neurological outcome and – if applied strictly in carefully selected individuals – overall survival in this otherwise doomed group of patients.

Conflict of interest

Bernd W. Böttiger is European Resuscitation Council (ERC) Board Director Science and Research; Chairman of the German Resuscitation Council (GRC); Member of the, Advanced Life Support (ALS) Task Force of the International Liaison Committee on Resuscitation (ILCOR); Member of the executive committee of the German Interdisciplinary Association for Intensive and Emergency Medicine (DIVI); Associated Editor of the European Journal of Anaesthesiology (EJA), Co-Editor of “Resuscitation”; Editor of

Acknowledgment

The study was not sponsored.

References (32)

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