Presentation and Outcomes of Adults With Overdose-Related Out-of-Hospital Cardiac Arrest.

Importance: Drug overdose (OD) is a public health challenge and an important cause of out-of-hospital cardiac arrest (OHCA). Existing studies evaluating OD-related OHCA (OD-OHCA) either aggregate all drugs or focus on opioids. The epidemiology, presentation, and outcomes of drug-specific OHCA are largely unknown. Objective: To evaluate the temporal pattern, clinical presentation, care, and outcomes of adult patients with OHCA overall and according to the drug-specific profile. Design, Setting, and Participants: This cohort study of adults with OHCA in King County Washington was conducted between January 1, 2015, and December 31, 2021. Etiology of OHCA was determined using emergency medical service, hospital, and medical examiner records. Etiology was classified as non-OD OHCA or OD-OHCA, with drug-specific profiles categorized as (1) opioid without stimulant, (2) stimulant without opioid, (3) opioid and stimulant, or (4) all other nonstimulant, nonopioid drugs. Statistical analysis was performed on July 1, 2023. Exposure: Out-of-hospital cardiac arrest. Main Outcomes and Measures: The primary outcome was survival to hospital discharge. The secondary outcome was survival with favorable functional status defined by Cerebral Performance Category 1 or 2 based on review of the hospital record. Results: In this cohort study, there were 6790 adult patients with emergency medical services-treated OHCA from a US metropolitan system. During the 7-year study period, there were 702 patients with OD-OHCA (median age, 41 years [IQR, 29-53 years]; 64% male [n = 450] and 36% female [n = 252]) and 6088 patients with non-OD OHCA (median age, 66 years [IQR, 56-77 years]; 65% male [n = 3944] and 35% female [n = 2144]). The incidence of OD-OHCA increased from 5.2 (95% CI, 3.8-6.6) per 100 000 person-years in 2015 to 13.0 (95% CI, 10.9-15.1) per 100 000 person-years in 2021 (P < .001 for trend), whereas there was no significant temporal change in the incidence of non-OD OHCA (P = .30). OD-OHCA were more likely to be unwitnessed (66% [460 of 702] vs 41% [2515 of 6088]) and less likely to be shockable (8% [56 of 702] vs 25% [1529 of 6088]) compared with non-OD OHCA. Unadjusted survival was not different (20% [138 of 702] for OD vs 18% [1095 of 6088] for non-OD). When stratified by drug profile, combined opioid-stimulant OHCA demonstrated the greatest relative increase in incidence. Presentation and outcomes differed by drug profile. Patients with stimulant-only OHCA were more likely to have a shockable rhythm (24% [31 of 129]) compared with patients with opioid-only OHCA (4% [11 of 295]) or patients with combined stimulant-opioid OHCA 5% [10 of 205]), and they were more likely to have a witnessed arrest (50% [64 of 129]) compared with patients with OHCA due to other drugs (19% [14 of 73]) or patients with combined stimulant-opioid OHCA (23% [48 of 205]). Patients with a combined opioid-stimulant OHCA had the lowest survival to hospital discharge (10% [21 of 205]) compared with patients with stimulant-only OHCA (22% [29 of 129]) or patients with OHCA due to other drugs (26% [19 of 73]), a difference that persisted after multivariable adjustment. Conclusions and Relevance: In a population-based cohort study, the incidence of OD-OHCA increased significantly from 2015 to 2021, with the greatest increase observed among patients with a combined stimulant-opioid OHCA. Presentation and outcome differed according to the drug-specific profile. The combination of increasing incidence and lower survival among among patients with a opioid-stimulant OHCA supports prevention and treatment initiatives that consider the drug-specific profile.

Association between bystander physical limitations, delays in chest compression during telecommunicator-assisted cardiopulmonary resuscitation, and outcome after out-of-hospital cardiac arrest.

BACKGROUND: Promptly initiated bystander cardiopulmonary resuscitation (CPR) improves survival from out-of-hospital cardiac arrest (OHCA). Many OHCA patients require repositioning to a firm surface. We examined the association between repositioning, chest compression (CC) delay, and patient outcomes. METHODS: We used a quality improvement registry from review of 9-1-1 dispatch audio recordings of OHCA among adults eligible for telecommunicator-assisted CPR (T-CPR) between 2013 and 2021. OHCA was categorized into 3 groups: CC not delayed, CC delayed due to bystander physical limitations to reposition the patient, or CC delayed for other (non-physical) reasons. The primary outcome was the repositioning interval, defined as the interval between the start of positioning instructions and CC onset. We used logistic regression to assess the odds ratio of survival according to CPR group, adjusting for potential confounders. RESULTS: Of the 3,482 OHCA patients eligible for T-CPR, CPR was not delayed in 1,223 (35%), delayed due to repositioning in 1,413 (41%), and delayed for other reasons in 846 (24%). The repositioning interval was longest for the physical limitation delay group (137 secs, IQR-148) compared to the other delay group (81 secs, IQR-70) and the no delay group (51 secs, IQR-32) (p < 0.001). Unadjusted survival was lowest in the physical limitation delay group (11%) versus the no delay (17%) and other delay (19%) groups and persisted after adjustment (p = 0.009). CONCLUSION: Bystander physical limitations are a common barrier to repositioning patients to begin CPR and are associated with lower likelihood of receiving CPR, longer times to begin CC, and lower survival.

Incidence, Mechanism, and Outcomes of On-Plane Versus Off-Plane Cardiac Arrest in Air Travelers.

Background Air travel affords an opportunity to evaluate resuscitation performance and outcome in a setting where automated external defibrillators (AEDs) are readily available. Methods and Results The study cohort included people aged ≥18 years with out of hospital cardiac arrest (OHCA) traveling through Seattle-Tacoma International Airport between January 1, 2004 and December 31, 2019 treated by emergency medical services (EMS). The primary outcomes were pre-EMS therapies (cardiopulmonary resuscitation, application of AED), return of spontaneous circulation, and survival to hospital discharge. Over the 16-year study period, there were 143 OHCA occurring before EMS arrival, 34 (24%) on-plane and 109 (76%) off-plane. Cardiac etiology (81%) was the most common mechanism of arrest. The majority of arrests were bystander-witnessed and presented with a shockable rhythm; these characteristics were more common in off-plane OHCA compared with on-plane (witnessed: 89% versus 74% and shockable: 72% versus 50%). Pre-EMS therapies including cardiopulmonary resuscitation and AED application were common regardless of arrest location. Compared with on-plane OHCA, off-plane OHCA was associated with greater rates of return of spontaneous circulation (68% versus 44%) and 3-fold higher rate of survival to hospital discharge (44% versus 15%). All survivors of on-plane OHCA had AED application with defibrillation before EMS arrival. Conclusions When applied to air travel volumes, we estimate 350 air travel-associated OHCA occur in the United States and 2000 OHCA worldwide each year, nearly a quarter of which happen on-plane. These events are survivable when early arrest interventions including rapid arrest recognition, AED application, and CPR are deployed.

Prehospital Patient Care Protocols for Suicidality in Washington State.

BACKGROUND: Patients with suicidal thoughts and behavior represent a growing proportion of patients who present for Emergency Department care. Many of these patients arrive via ambulance. Several brief suicide- or self-harm-specific interventions have been developed for implementation in the Emergency Department setting. However, there is a dearth of training resources, patient care guidelines, and policy guidance to assist prehospital care providers in the treatment of EMS patients who are suicidal. We evaluated prehospital patient care protocols in Washington State to assess for the presence-absence of any suicide and/or self-harm specific protocols, as well as the inclusion of procedures above and beyond conventional approaches to scene safety and transport to the Emergency Department. METHODS: Prehospital patient care protocols were obtained for all counties in Washington State. Researchers rated protocols across seven domains, including the mention of any suicide- or self-harm-specific procedures. RESULTS: Approximately one-third of counties had any suicide- or self-harm-specific content in prehospital patient care protocols. There was no association between county-level rurality-urbanicity and the presence-absence of suicide- or self-harm-specific care. CONCLUSION: These findings demonstrated that little guidance exists for EMS providers in Washington State with regard to the screening or treatment of suicidal patients, above and beyond scene safety and transportation to hospital-based care. Development of guidelines for prehospital suicide care, as well as enhanced screening, assessment, and collaboration with on-call crisis resources has the potential to expand the scope of prehospital treatment for suicidal patients, and reduce burdens on patients, EMS providers, and Emergency Departments.

Clinical Characteristics of Patients With Coronavirus Disease 2019 (COVID-19) Receiving Emergency Medical Services in King County, Washington.

Importance: The ability to identify patients with coronavirus disease 2019 (COVID-19) in the prehospital emergency setting could inform strategies for infection control and use of personal protective equipment. However, little is known about the presentation of patients with COVID-19 requiring emergency care, particularly those who used 911 emergency medical services (EMS). Objective: To describe patient characteristics and prehospital presentation of patients with COVID-19 cared for by EMS. Design, Setting, and Participants: This retrospective cohort study included 124 patients who required 911 EMS care for COVID-19 in King County, Washington, a large metropolitan region covering 2300 square miles with 2.2 million residents in urban, suburban, and rural areas, between February 1, 2020, and March 18, 2020. Exposures: COVID-19 was diagnosed by reverse transcription-polymerase chain reaction detection of severe acute respiratory syndrome coronavirus 2 from nasopharyngeal swabs. Test results were available a median (interquartile range) of 5 (3-9) days after the EMS encounter. Main Outcomes and Measures: Prevalence of clinical characteristics, symptoms, examination signs, and EMS impression and care. Results: Of the 775 confirmed COVID-19 cases in King County, EMS responded to 124 (16.0%), with a total of 147 unique 911 encounters. The mean (SD) age was 75.7 (13.2) years, 66 patients (53.2%) were women, 47 patients (37.9%) had 3 or more chronic health conditions, and 57 patients (46.0%) resided in a long-term care facility. Based on EMS evaluation, 43 of 147 encounters (29.3%) had no symptoms of fever, cough, or shortness of breath. Based on individual examination findings, fever, tachypnea, or hypoxia were only present in a limited portion of cases, as follows: 43 of 84 encounters (51.2%), 42 of 131 (32.1%), and 60 of 112 (53.6%), respectively. Advanced care was typically not required, although in 24 encounters (16.3%), patients received care associated with aerosol-generating procedures. As of June 1, 2020, mortality among the study cohort was 52.4% (65 patients). Conclusions and Relevance: The findings of this cohort study suggest that screening based on conventional COVID-19 symptoms or corresponding examination findings of febrile respiratory illness may not possess the necessary sensitivity for early diagnostic suspicion, at least in the prehospital emergency setting. The findings have potential implications for early identification of COVID-19 and effective strategies to mitigate infectious risk during emergency care.

Usual Care for Emergency Department Patients Who Present with Suicide Risk: A Survey of Hospital Procedures in Washington State.

Hospital emergency departments (EDs) are important settings for the implementation of effective suicide-specific care. Usual care for suicidal patients who present to EDs remains understudied. This study surveyed EDs in Washington State to assess the adoption of written procedures for recommended standards of care for treating suicidality. Most (N = 79, 84.9%) of the 93 EDs in Washington State participated. Most (n = 58, 73.4%) hospitals had a written protocol for suicide risk assessment, but half (n = 42, 53.2%) did not include documentation of access to lethal means. There was evidence of an association between patient volume and the adoption of suicide-specific protocols and procedures. Our findings suggest the need to enhance the adoption and implementation of recommended standard care in this setting.