Inclined position is associated with improved first pass success and laryngoscopic view in prehospital endotracheal intubations.

PURPOSE: In hospital-based studies, patients intubated by physicians while in an inclined position compared to supine position had a higher rate of first pass success and lower rate of peri-intubation complications. We evaluated the impact of patient positioning on prehospital endotracheal intubation in an EMS system with rapid sequence induction capability. We hypothesized that patients in the inclined position would have a higher first-pass success rate. METHODS: Prehospital endotracheal intubation cases performed by paramedics between 2012 and 2017 were prospectively collected in airway registries maintained by a metropolitan EMS system. We included all adult (age ≥ 18 years) non-traumatic, non-arrest patients who received any attempt at intubation. Patients were categorized according to initial positioning: supine or inclined. The primary outcome measure was first pass success with secondary outcomes of laryngoscopic view and challenges to intubation. RESULTS: Of the 13,353 patients with endotracheal intubation attempted by paramedics during the study period, 4879 were included for analysis. Of these, 1924 (39.4%) were intubated in the inclined position. First pass success was 86.3% among the inclined group versus 82.5% for the supine group (difference 3.8%, 95% CI: 1.5%-6.1%). First attempt laryngeal grade I view was 62.9% in the inclined group versus 57.1% for the supine group (difference 5.8%, 2.0-9.6). Challenges to intubation were more frequent in the supine group (42.3% versus 38.8%, difference 3.5%, 0.6-6.3). CONCLUSION: Inclined positioning was associated with a better grade view and higher rate of first pass success. The technique should be considered as a viable approach for prehospital airway management.

Simulation training to improve 9-1-1 dispatcher identification of cardiac arrest: A randomized controlled trial.

BACKGROUND: The objective of this study was to test the effectiveness of simulation training, using actors to make mock calls, on improving Emergency Medical Dispatchers' (EMDs) ability to recognize the need for, and reduce the time to, telephone-assisted CPR (T-CPR) in simulated and real cardiac arrest 9-1-1 calls. METHODS: We conducted a parallel prospective randomized controlled trial with n=157 EMDs from thirteen 9-1-1 call centers. Study participants were randomized within each center to intervention (i.e., completing 4 simulation training sessions over 12-months) or control (status quo). After the intervention period, performance on 9 call processing skills and 2 time-intervals were measured in 2 simulation assessment calls for both arms. Six of the 13 call centers provided recordings of real cardiac arrest calls taken by study participants during the study period. RESULTS: Of the N=128 EMDs who completed the simulation assessment, intervention participants (n=66) performed significantly better on 6 of 9 call processing skills and started T-CPR 23s faster (73 vs 91s respectively, p<0.001) compared to participants in the control arm (n=62). In real cardiac arrest calls, EMDs who completed 3 or 4 training sessions were more likely to recognize the need for T-CPR for more challenging cardiac arrest calls than EMDs who completed fewer than 3, including controls who completed no training (68% vs 53%, p=0.018). CONCLUSIONS: Simulation training improves call processing skills and reduces time to T-CPR in simulated call scenarios, and may improve the recognition of the need for T-CPR in more challenging real-life cardiac arrest calls. CLINICAL TRIAL REGISTRATION: http://www.clinicaltrials.gov Trial # NCT01972087.

Socioeconomic status and survival from ventricular fibrillation out-of-hospital cardiac arrest.

PURPOSE: Out-of-hospital cardiac arrest (OHCA) is a major cause of death in the United States. How individual-level socioeconomic status (SES) influences survival is uncertain. METHODS: The investigation is a retrospective cohort study of adults who suffered OHCA and presented with a shockable rhythm in a metropolitan county from January 1, 1999-December 31, 2005. Individual-level measures of SES were obtained from vital records and surveys. SES measures included education and occupation. We used multivariable logistic regression to assess the independent association between SES measures and survival to hospital discharge. RESULTS: Of the 1390 eligible OHCA patients, 374 (27%) survived to hospital discharge. Compared to those with less than high school diploma, the multivariable-adjusted odds ratio of survival was 1.36 (95% confidence interval [CI], 0.87-2.14) for high school graduates, 1.54 (95% CI, 0.95-2.48) for those with some college, and 1.96 (95% CI, 1.17-3.27) for those with college degrees (test for trend across the categories P < .001). We did not observe an independent association between occupation and survival. CONCLUSIONS: Higher education was associated with greater survival after OHCA. This relationship was not explained by key demographic or clinical characteristics. A better understanding of the mechanism by which individual-level SES characteristics influence prognosis may provide opportunities to improve survival.

Protocol: simulation training to improve 9-1-1 dispatcher identification of cardiac arrest.

BACKGROUND: 9-1-1 dispatchers are often the first contact for bystanders witnessing an out-of-hospital cardiac arrest. In the time before Emergency Medical Services arrives, dispatcher identification of the need for, and provision of Telephone-CPR (T-CPR) can improve survival. Our study aims to evaluate the use of phone-based standardized patient simulation training to improve identification of the need for T-CPR and shorten time to start of T-CPR instructions. METHODS/DESIGN: The STAT-911 study is a randomized controlled trial. We will recruit 160 dispatchers from 9-1-1 call-centers in the Pacific Northwest; they are randomized to an intervention or control group. Intervention participants complete four telephone simulation training sessions over 6-8 months. Training sessions consist of three mock 9-1-1 calls, with a standardized patient playing a caller witnessing a medical emergency. After the mock calls, an instructor who has been listening in and scoring the dispatcher's call management, connects to the dispatcher and provides feedback on select call processing skills. After the last training session, all participants complete the simulation test: a call session that includes two mock 9-1-1 calls of medium complexity. During the study, audio from all actual cardiac arrest calls handled by the dispatchers will be collected. All dispatchers complete a baseline survey, and after the intervention, a follow-up survey to measure confidence. Primary outcomes are proportion of calls where dispatchers identify the need for T-CPR, and time to start of T-CPR, assessed by comparing performance on two calls in the simulation test. Secondary outcomes are proportion of actual cardiac arrest calls in which dispatchers identify the need for T-CPR and time to start of T-CPR; performance on call-taking skills during the simulation test; self-reported confidence in the baseline and follow-up surveys; and calculated costs of the intervention training sessions and projected costs for field implementation of training sessions. DISCUSSION: The STAT-911 study will evaluate if over-the-phone simulation training with standardized patients can improve 9-1-1 dispatchers' ability identify the need for, and promptly begin T-CPR. Furthermore, it will advance knowledge on the effectiveness of simulation training for health services phone-operators interacting with clients, patients, or bystanders in diagnosis, triage, and treatment decisions. TRIAL REGISTRATION: ClinicalTrials.gov REGISTRATION NUMBER: NCT01972087 . Registered 23 October 2013.

Common variation in fatty acid genes and resuscitation from sudden cardiac arrest.

BACKGROUND: Fatty acids provide energy and structural substrates for the heart and brain and may influence resuscitation from sudden cardiac arrest (SCA). We investigated whether genetic variation in fatty acid metabolism pathways was associated with SCA survival. METHODS AND RESULTS: Subjects (mean age, 67 years; 80% male, white) were out-of-hospital SCA patients found in ventricular fibrillation in King County, WA. We compared subjects who survived to hospital admission (n=664) with those who did not (n=689), and subjects who survived to hospital discharge (n=334) with those who did not (n=1019). Associations between survival and genetic variants were assessed using logistic regression adjusting for age, sex, location, time to arrival of paramedics, whether the event was witnessed, and receipt of bystander cardiopulmonary resuscitation. Within-gene permutation tests were used to correct for multiple comparisons. Variants in 5 genes were significantly associated with SCA survival. After correction for multiple comparisons, single-nucleotide polymorphisms in ACSL1 and ACSL3 were significantly associated with survival to hospital admission. Single-nucleotide polymorphisms in ACSL3, AGPAT3, MLYCD, and SLC27A6 were significantly associated with survival to hospital discharge. CONCLUSIONS: Our findings indicate that variants in genes important in fatty acid metabolism are associated with SCA survival in this population.

Impact of changes in resuscitation practice on survival and neurological outcome after out-of-hospital cardiac arrest resulting from nonshockable arrhythmias.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) claims millions of lives worldwide each year. OHCA survival from shockable arrhythmias (ventricular fibrillation/ tachycardia) improved in several communities after implementation of American Heart Association resuscitation guidelines that eliminated "stacked" shocks and emphasized chest compressions. "Nonshockable" rhythms are now the predominant presentation of OHCA; the benefit of such treatments on nonshockable rhythms is uncertain. METHODS AND RESULTS: We studied 3960 patients with nontraumatic OHCA from nonshockable initial rhythms treated by prehospital providers in King County, Washington, over a 10-year period. Outcomes during a 5-year intervention period after adoption of new resuscitation guidelines were compared with the previous 5-year historical control period. The primary outcome was 1-year survival. Patient demographics and resuscitation characteristics were similar between the control (n=1774) and intervention (n=2186) groups, among whom 471 of 1774 patients (27%) versus 742 of 2186 patients (34%), respectively, achieved return of spontaneous circulation; 82 (4.6%) versus 149 (6.8%) were discharged from hospital, 60 (3.4%) versus 112 (5.1%) with favorable neurological outcome; 73 (4.1%) versus 135 (6.2%) survived 1 month; and 48 (2.7%) versus 106 patients (4.9%) survived 1 year (all P≤0.005). After adjustment for potential confounders, the intervention period was associated with an improved odds of 1.50 (95% confidence interval, 1.29-1.74) for return of spontaneous circulation, 1.53 (95% confidence interval, 1.14-2.05) for hospital survival, 1.56 (95% confidence interval, 1.11-2.18) for favorable neurological status, 1.54 (95% confidence interval, 1.14-2.10) for 1-month survival, and 1.85 (95% confidence interval, 1.29-2.66) for 1-year survival. CONCLUSION: Outcomes from OHCA resulting from nonshockable rhythms, although poor by comparison with shockable rhythm presentations, improved significantly after implementation of resuscitation guideline changes, suggesting their potential to benefit all presentations of OHCA.

Bystander CPR in out-of-hospital cardiac arrest: the role of limited English proficiency.

BACKGROUND: The proportion of non-native English speakers is increasing in the United States. We sought to determine if limited English proficiency in callers to 9-1-1 for out-of-hospital cardiac arrest is associated with provision of bystander cardiopulmonary resuscitation (CPR) and delays in telephone-assisted CPR. MATERIALS AND METHODS: We completed a secondary analysis of cohort data collected as part of a randomized trial of emergency dispatcher bystander CPR instructions. Included patients suffered confirmed cardiac arrest treated by emergency medical services. Callers were identified as limited English proficient through review of the dispatcher report. RESULTS: Of 971 eligible cardiac arrest cases, 5.9% (n = 57) of 9-1-1 callers were limited English proficient. Comparing arrest events of limited English proficient 9-1-1 callers with English-fluent callers, a lower proportion of limited English proficient arrest cases received bystander CPR (64.3% [36/56] vs. 77.5% [702/906]; p = 0.02) or survived to hospital discharge (8.8% [5/57] vs. 16.5% [151/914]; p = 0.12). Dispatchers took longer to recognize cardiac arrest with limited English proficient callers compared with English-fluent callers (median 84 vs. 50s; p < 0.001). Among callers attempting bystander CPR, the interval from call receipt to initiation of CPR was longer for limited English proficient compared with English-fluent callers (median 237 vs. 163s; p < 0.001). CONCLUSION: In this observational study of dispatcher-identified cardiac arrest, limited English proficiency in 9-1-1 callers was associated with less frequent provision of bystander CPR and delays in arrest recognition and implementation of telephone CPR, underscoring the health challenges and potential disparities of pre-hospital care related to limited English proficiency.

Procainamide and survival in ventricular fibrillation out-of-hospital cardiac arrest.

OBJECTIVES: Procainamide is an antiarrhythmic drug of unproven efficacy in cardiac arrest. The association between procainamide and survival from out-of-hospital cardiac arrest was investigated to better determine the drug's potential role in resuscitation. METHODS: The authors conducted a 10-year study of all witnessed, out-of-hospital, ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) cardiac arrests treated by emergency medical services (EMS) in King County, Washington. Patients were considered eligible for procainamide if they received more than three defibrillation shocks and intravenous (IV) bolus lidocaine. Four logistic regression models were used to calculate odds ratios (ORs) and 95% confidence intervals (CI) describing the relationship between procainamide and survival. RESULTS: Of the 665 eligible patients, 176 received procainamide, and 489 did not. On average, procainamide recipients received more shocks and pharmacologic interventions and had lengthier resuscitations. Adjusted for their clinical and resuscitation characteristics, procainamide recipients had a lower likelihood of survival to hospital discharge (OR = 0.52; 95% CI = 0.36 to 0.75). Further adjustment for receipt of other cardiac medications during resuscitation negated this apparent adverse association (OR = 1.02; 95% CI = 0.66 to 1.57). CONCLUSIONS: In this observational study of out-of-hospital VF and pulseless VT arrest, procainamide as second-line antiarrhythmic treatment was not associated with survival in models attempting to best account for confounding. The results suggest that procainamide, as administered in this investigation, does not have a large impact on outcome, but cannot eliminate the possibility of a smaller, clinically relevant effect on survival.

The relationship between time to arrival of emergency medical services (EMS) and survival from out-of-hospital ventricular fibrillation cardiac arrest.

AIM: We examined the relationship between time from collapse to arrival of emergency medical services (EMS) and survival to hospital discharge for out-of-hospital ventricular fibrillation cardiac arrests in order to determine meaningful interpretations of this association. METHODS: We calculated survival rates in 1-min intervals from collapse to EMS arrival. Additionally, we used logistic regression to determine the absolute probability of survival per minute of delayed EMS arrival. We created a logistic regression model with spline terms for the time variable to examine the decline in survival in intervals that are hypothesized to be physiologically relevant. RESULTS: The observed data showed survival declined, on average, by 3% for each minute that EMS was delayed following collapse. Survival rates did not decline appreciably if the time between collapse and arrival of EMS was 4 min or less but they declined by 5.2% per minute between 5 and 10 min. EMS arrival 11-15 min after collapse showed a less steep decline in survival of 1.9% per minute. The spline model that incorporated changes in slope in the time interval variable modeled this relationship more accurately than a model with a continuous term for time (p=0.01). CONCLUSIONS: The results of our analyses show that survival from out-of-hospital cardiac arrest does not decline at a constant rate following collapse. Models that incorporate changes that reflect the physiological alterations that occur following cardiac arrests are a more accurate way to describe changes in survival rates over time than models that include only a continuous term for time.

Prompt advanced life support improves survival from ventricular fibrillation.

OBJECTIVE: To determine whether the interval between the arrival of basic life support (BLS) providers and the arrival of advanced life support (ALS) providers is associated with patient outcome after cardiac arrest. METHODS: We conducted a retrospective cohort study of all witnessed, out-of-hospital ventricular fibrillation (VF) cardiac arrests between January 1, 1991, and December 31, 2007. Eligible patients (n = 1,781) received full resuscitation efforts from both BLS and ALS providers. RESULTS: The BLS-to-ALS arrival interval was a significant predictor of survival to hospital discharge (odds ratio [OR] 0.96, 95% confidence interval [CI] 0.93-0.99); the likelihood of survival decreased by 4% for every minute that ALS arrival was delayed following BLS arrival. Other significant predictors of survival were whether the arrest occurred in public (OR 1.48, 95% CI 1.19-1.85), whether a bystander administered cardiopulmonary resuscitation (CPR) (OR 1.34, 95% CI 1.07-1.68), and the interval between the 9-1-1 call and BLS arrival (OR 0.78, 95% CI 0.73-0.83). CONCLUSIONS: We found that a shorter BLS-to-ALS arrival interval increased the likelihood of survival to hospital discharge after a witnessed, out-of-hospital VF cardiac arrest. We conclude that ALS interventions may provide additional benefits over BLS interventions alone when utilized in a well-established, two-tiered emergency medical services (EMS) system already optimized for rapid defibrillation. The highest priorities in any EMS system should still be early CPR and early defibrillation, but timely ALS services can supplement these crucial interventions.

Public access defibrillation in out-of-hospital cardiac arrest: a community-based study.

BACKGROUND: The dissemination and use of automated external defibrillators (AEDs) beyond traditional emergency medical services (EMS) into the community has not been fully evaluated. We evaluated the frequency and outcome of non-EMS AED use in a community experience. METHODS AND RESULTS: The investigation was a cohort study of out-of-hospital cardiac arrest cases due to underlying heart disease treated by public access defibrillation (PAD) between January 1, 1999, and December 31, 2002, in Seattle and surrounding King County, Washington. Public access defibrillation was defined as out-of-hospital cardiac arrest treated with AED application by persons outside traditional emergency medical services. The EMS of Seattle and King County developed a voluntary Community Responder AED Program and registry of PAD AEDs. During the 4 years, 475 AEDs were placed in a variety of settings, and more than 4000 persons were trained in cardiopulmonary resuscitation and AED operation. A total of 50 cases of out-of-hospital cardiac arrest were treated by PAD before EMS arrival, which represented 1.33% (50/3754) of all EMS-treated cardiac arrests. The proportion treated by PAD AED increased each year, from 0.82% in 1999 to 1.12% in 2000, 1.41% in 2001, and 2.05% in 2002 (P=0.019, test for trend). Half of the 50 persons treated with PAD survived to hospital discharge, with similar survival for nonmedical settings (45% [14/31]) and out-of-hospital medical settings (58% [11/19]). CONCLUSIONS: PAD was involved in only a small but increasing proportion of out-of-hospital cardiac arrests.

Emergency medical services and mortality from heart disease: a community study.

STUDY OBJECTIVES: Little is known regarding the potential effects of emergency medical services (EMS) on total heart disease mortality. Although EMS may provide health benefits in less acute cardiac conditions, its immediate, measurable, and direct effect on heart disease mortality is through resuscitation of persons suffering out-of-hospital cardiac arrest. The purpose of this study was to examine the involvement and potential mortality benefit of out-of-hospital EMS care of cardiac arrest on community heart disease mortality. METHODS: The investigation was an observational study of all persons with death events resulting from heart disease as defined by heart disease deaths and deaths averted (persons successfully resuscitated from out-of-hospital cardiac arrest by EMS) in a single county from January 1, 2000, through December 31, 2000. The county of study has a population of nearly 2 million people and is composed of urban, suburban, and rural components. State vital records and EMS reports were used to ascertain deaths resulting from heart disease and deaths averted. RESULTS: In the year 2000, 3,577 persons died as a result of heart disease, and 128 persons were successfully resuscitated and discharged from the hospital, for a total of 3,705 death events. EMS responded to 39% (1,428/3,705) of all heart disease death events and 57% (1,428/2,516) of out-of-hospital events, resulting in a 3.5% (128/3,705) reduction in overall heart disease mortality and a 5.1% (128/2,516) reduction in out-of-hospital mortality. CONCLUSION: EMS was involved in the majority of out-of-hospital heart disease death events, resulting in a measurable reduction in heart disease mortality.

Changing incidence of out-of-hospital ventricular fibrillation, 1980-2000.

CONTEXT: Recent reports from 2 European cities and an earlier observation from Seattle, Wash, suggest that the number of patients treated for out-of-hospital ventricular fibrillation (VF) has declined. OBJECTIVE: To analyze the incidence of cardiac arrest and to examine relationships among incidence, sex, race, age, and first identified cardiac rhythm in Seattle. DESIGN, SETTING, AND PATIENTS: Population-based study of all cardiac arrest cases with presumed cardiac etiology who received advanced life support from Seattle Fire Department emergency medical services during specified periods between 1979 and 2000. United States Census data for Seattle in 1980, 1990, and 2000 were used to determine incidence rates for treated cardiac arrest with adjustments for age and sex. MAIN OUTCOME MEASURES: Changes in incidence of cardiac arrest and initial recorded cardiac rhythm. RESULTS: The adjusted annual incidence of cardiac arrest with VF as the first identified rhythm decreased by about 56% from 1980 to 2000 (from 0.85 to 0.38 per 1000; relative risk [RR], 0.44; 95% confidence interval [CI], 0.37-0.53). Similar reductions occurred in blacks (54%; RR, 0.45; 95% CI, 0.26-0.79) and whites (53%; RR, 0.47; 95% CI, 0.38-0.58) and was most evident in men (57%; RR, 0.43; 95% CI, 0.35-0.53), in whom the baseline incidence was relatively high. When all treated arrests with presumed cardiac etiology were considered, that incidence decreased by 43% (RR, 0.58; 95% CI, 0.49-0.67) in men but negligibly in women, for whom a relatively low incidence of VF also declined but was offset by more cases with asystole or pulseless electrical activity. CONCLUSION: We observed a major decline in the incidence of out-of-hospital VF and in all cases of treated cardiac arrest presumably due to heart disease in Seattle. These changes likely reflect the national decline in coronary heart disease mortality.