Clinical paperOne year experience with fast track algorithm in patients with refractory out-of-hospital cardiac arrest
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)
- et al.
Epidemiology and outcomes from out-of-hospital cardiac arrests in England
Resuscitation
(2017) - et al.
Health related quality of life after extracorporeal cardiopulmonary resuscitation in refractory cardiac arrest
Resuscitation
(2018) - et al.
Impact of the direct transfer to percutaneous coronary intervention-capable hospitals on survival to hospital discharge for patients with out-of-hospital cardiac arrest
Resuscitation
(2018) - et al.
Direct transport to a PCI-capable hospital is associated with improved survival after adult out-of-hospital cardiac arrest of medical aetiology
Resuscitation
(2018) - et al.
Extracorporeal cardiopulmonary resuscitation for cardiac arrest: a systematic review
Resuscitation
(2018) - et al.
European Resuscitation Council Guidelines for Resuscitation: 2017 update
Resuscitation
(2018) - et al.
Coronary artery disease in patients with out-of-hospital refractory ventricular fibrillation cardiac arrest
J Am Coll Cardiol
(2017) - et al.
The incidence of "load&go" out-of-hospital cardiac arrest candidates for emergency department utilization of emergency extracorporeal life support: a one-year review
Resuscitation
(2015) - et al.
Prognostic factors for extracorporeal cardiopulmonary resuscitation recipients following out-of-hospital refractory cardiac arrest. A systematic review and meta-analysis
Resuscitation
(2017) - et al.
Association between delay to coronary reperfusion and outcome in patients with acute coronary syndrome undergoing extracorporeal cardiopulmonary resuscitation
Resuscitation
(2017)
Recommended guidelines for reviewing, reporting, and conducting research on post-resuscitation care: the Utstein style
Resuscitation
European Resuscitation Council Guidelines for Resuscitation 2015: section 3. Adult advanced life support
Resuscitation
European Resuscitation Council Guidelines for Resuscitation: 2018 update — antiarrhythmic drugs for cardiac arrest
Resuscitation
Out-of-hospital cardiac arrest outcomes stratified by rhythm analysis
Resuscitation
Exploring which patients without return of spontaneous circulation following ventricular fibrillation out-of-hospital cardiac arrest should be transported to hospital?
Resuscitation
Trial of continuous or interrupted chest compressions during CPR
N Engl J Med
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