Infant out-of-hospital cardiac arrest during nights and weekends.

BACKGROUND: A growing body of evidence suggests outcomes for cardiac arrest in adults are worse during nights and weekends when compared with daytime and weekdays. Similar research has not yet been carried out in the infant setting. METHODS: We examined the National Emergency Medical Services Information System (NEMSIS), a database containing millions of emergency medical services (EMS) runs in the United States. Inclusion criteria were infant out-of-hospital cardiac arrests (patients <1 years old) taking place prior to EMS arrival between January 2021 and December 2022 where EMS documented whether return of spontaneous circulation (ROSC) was achieved. Cardiac arrests were classified as occurring during either the day (defined as 0800-1959) or the night (defined as 2000-0759) and weekends (Saturday/Sunday) or weekdays (Monday-Friday). Rates of ROSC achievement were compared. RESULTS: A total of 8549 infant cardiac arrests met inclusion criteria: 5074 (59.4%) took place during daytime compared with 3475 (40.6%) during nighttime, and 5989 (70.1%) arrests occurred on weekdays compared with 2560 (29.9%) on weekends. Rates of ROSC achievement were significantly lower on weekends versus weekdays (16.8% vs. 14.1%; p = 0.00097). A difference in ROSC rates when comparing daytime and nighttime was seen, but this difference was not statistically significant (16.4% vs. 15.3%; p = 0.08076). CONCLUSION: ROSC achievement rates for infant out-of-hospital cardiac arrest are significantly lower on weekends when compared with weekdays. Further study and quality improvement work is needed to better understand this.

The Public Health and Economic Impact of Drug Overdose Out-of-Hospital Cardiac Arrest in the United States.

OBJECTIVE: To calculate disability-adjusted life years (DALY) and labor productivity loss due to drug overdose out-of-hospital cardiac arrest (DO-OHCA) and compare its contribution to the burden of disease and economic impact of all-cause nontraumatic out-of-hospital cardiac arrest (OHCA) in the US. METHODS: We performed a retrospective observational cohort analysis of all adult (age ≥18 years) nontraumatic emergency medical services-treated OHCA events, including those due to DO-OHCA, from the national Cardiac Arrest Registry to Enhance Survival (CARES) database from January 1, 2017 and December 31, 2020. The main outcome measures of interest were disability-adjusted life years, annual, and lifetime labor productivity loss over the 4-year study period. The findings for the study population were extrapolated to a national level using the CARES population catchment and U.S. population estimates by year. RESULTS: A total of 378,088 adult OHCA events, including 23,252 DO-OHCA (6.2%) met study inclusion criteria. The DO-OHCA DALY increased from 156,707 in 2017 to 265,692 in 2020. Per year, DO-OHCA contributed to 11.4%, 12.0%, 10.5%, and 11.4% of all OHCA DALY lost from 2017-2020, respectively. The mean annual and lifetime productivity losses for all OHCA were stable over time (annual: $47K in 2017 to $50K in 2020; lifetime: $647K in 2017 to $692K in 2020). The CARES population catchment increased by 39.8% over the study period (102.6 M in 2017 to 143.4 M in 2020). For DO-OHCA, the mean annual productivity loss was approximately 30% higher than non-DO-OHCA ($64K vs. $49K in 2020, respectively). The mean lifetime productivity loss for DO-OHCA was 2.5 times higher than non-DO-OHCA ($1.6 M vs. $630K in 2020, respectively). CONCLUSIONS: The DALY due to DO-OHCA has increased over time with expansion of the CARES dataset, but its relative contribution to total OHCA DALY (all non-traumatic etiologies) remained fairly stable. The DO-OHCAs represent approximately 6% of all adult non-traumatic EMS-treated OHCA events but has a disproportionately greater economic impact. Continued efforts to reduce DO-OHCA through public health initiatives are warranted to lessen the societal impact of OHCA in the U.S.

Validity of Computer-interpreted "Normal" and "Otherwise Normal" ECG in Emergency Department Triage Patients.

Introduction: Chest pain is the second most common chief complaint for patients undergoing evaluation in emergency departments (ED) in the United States. The American Heart Association recommends immediate physician interpretation of all electrocardiograms (ECG) performed for adults with chest pain within 10 minutes to evaluate for the finding of ST-elevation myocardial infarction (STEMI). The ECG machines provide computerized interpretation of each ECG, potentially obviating the need for immediate physician analysis; however, the reliability of computer-interpreted findings of "normal" or "otherwise normal" ECG to rule out STEMI requiring immediate intervention in the ED is unknown. Methods: We performed a prospective cohort analysis of 2,275 ECGs performed in triage in the adult ED of a single academic medical center, comparing the computerized interpretations of "normal" and "otherwise normal" ECGs to those of attending cardiologists. ECGs were obtained with a GE MAC 5500 machine and interpreted using Marquette 12SL. Results: In our study population, a triage ECG with a computerized interpretation of "normal" or "otherwise normal" ECG had a negative predictive value of 100% for STEMI (one-sided, lower 97.5% confidence interval 99.6%). None of the studied patients with these ECG interpretations had a final diagnosis of STEMI, acute coronary syndrome, or other diagnosis requiring emergent cardiac catheterization. Conclusion: In our study population, ECG machine interpretations of "normal" or "otherwise normal" ECG excluded findings of STEMI. The ECGs with these computerized interpretations could safely wait for physician interpretation until the time of patient evaluation without delaying an acute STEMI diagnosis.

Influence of Patient and Clinician Gender on Emergency Department HEART Scores: A Secondary Analysis of a Prospective Observational Trial.

STUDY OBJECTIVE: Clinical decision aids can decrease health care disparities. However, many clinical decision aids contain subjective variables that may introduce clinician bias. The HEART score is a clinical decision aid that estimates emergency department (ED) patients' cardiac risk. We sought to explore patient and clinician gender's influence on HEART scores. METHODS: In this secondary analysis of a prospective observational trial, we examined a convenience sample of adult ED patients at one institution presenting with acute coronary syndrome symptoms. We compared ED clinician-generated HEART scores with researcher-generated HEART scores blinded to patient gender. The primary outcome was agreement between clinician and researcher HEART scores by patient gender overall and stratified by clinician gender. Analyses used difference-in-difference (DiD) for continuous score and prevalence-adjusted, bias-adjusted Kappa (PABAK) for binary (low versus moderate/high risk) score comparison. RESULTS: All 336 clinician-patient pairs from the original study were included. In total, 47% (158/336) of patients were women, and 52% (174/336) were treated by a woman clinician. The DiD between clinician and researcher HEART scores among men versus women patients was 0.24 (95% CI -0.01 to 0.48). Compared with researchers, men clinicians assigned a higher score to men versus women patients (DiD 0.51 [95% CI 0.16 to 0.87]), whereas women clinicians did not (DiD 0.00 [95% CI -0.33 to 0.33]). Agreement was the highest among women clinicians (PABAK 0.72; 95% CI 0.61 to 0.81) and lowest among men clinicians assessing men patients (PABAK 0.47; 95% CI 0.29 to 0.66). CONCLUSION: Patient and clinician gender may influence HEART scores. Researchers should strive to understand these influences in developing and implementing this and other clinical decision aids.

Cardiac Arrest Following Drug Overdose in the United States: An Analysis of the Cardiac Arrest Registry to Enhance Survival.

BACKGROUND: Given increases in drug overdose-associated mortality, there is interest in better understanding of drug overdose out-of-hospital cardiac arrest (OHCA). A comparison between overdose-attributable OHCA and nonoverdose-attributable OHCA will inform public health measures. METHODS AND RESULTS: We analyzed data from 2017 to 2021 in the Cardiac Arrest Registry to Enhance Survival (CARES), comparing overdose-attributable OHCA (OD-OHCA) with OHCA from other nontraumatic causes (non-OD-OHCA). Arrests involving patients <18 years, health care facility residents, patients with cancer diagnoses, and patients with select missing data were excluded. Our main outcome of interest was survival with good neurological outcome, defined as Cerebral Performance Category score 1 or 2. From a data set with 537 100 entries, 29 500 OD-OHCA cases and 338 073 non-OD-OHCA cases met inclusion criteria. OD-OHCA cases involved younger patients with fewer comorbidities, were less likely to be witnessed, and less likely to present with a shockable rhythm. Unadjusted survival to hospital discharge with Cerebral Performance Category score =1 or 2 was significantly higher in the OD-OHCA cohort (OD: 15.2% versus non-OD: 6.9%). Adjusted results showed comparable survival with Cerebral Performance Category score =1 or 2 when the first monitored arrest rhythm was shockable (OD: 28.9% versus non-OD: 23.5%, P=0.087) but significantly higher survival rates with Cerebral Performance Category score =1 or 2 for OD-OHCA when the first monitored arrest rhythm was nonshockable (OD: 9.6% versus non-OD: 3.1%, P<0.001). CONCLUSIONS: Among patients presenting with nonshockable rhythms, OD-OHCA is associated with significantly better outcomes. Further research should explore cardiac arrest causes, and public health efforts should attempt to reduce the burden from drug overdoses.

Predicting Neurologically Intact Survival for Advanced Age Adults After Successful Resuscitation of Out-of-Hospital Cardiac Arrest.

We sought to predict survival to hospital discharge with favorable neurologic outcome for advanced age adults (≥65 years) after successful resuscitation of non-traumatic out-of-hospital cardiac arrest (OHCA). A retrospective observational cohort analysis was performed using the national Cardiac Arrest Registry to Enhance Survival database from January 1, 2013 to December 31, 2021. All nontraumatic OHCA occurring in advanced age adults who survived to hospital admission were included. The primary outcome was survival with favorable neurologic outcome defined as a cerebral performance category score of 1 or 2 at hospital discharge. Multivariable logistic regression including patient variables (age category, gender, co-morbidities) and OHCA characteristics (location, rhythm category, witnessed status, and who initiated cardiopulmonary resuscitation) were used to predict hospital outcome. 83,574 patients met study inclusion criteria with 19,298 (23.1%) surviving with favorable neurologic outcome. The median age was 75 years (interquartile range 69 to 82 years), 58.9% were male, and a majority of events occurred at home (67.3%). Age was found to have a linear, negative association with outcome. Survival with cerebral performance category 1 or 2 ranged from 28.8% in those between the age of 65 to 69 years (n = 23,161) and 13.7% for those age >90 years (n = 4,666). The regression model produced outcome probabilities ranging from 2.6% to 80.8% with a cross-validated AUROC of 0.742 (95% confidence interval 0.738 to 0.746) and a Brier score of 0.151. In conclusion, a simple model with basic patient and OHCA characteristics can predict hospital outcomes in advanced age adults with good discrimination and calibration.

Disability-Adjusted Life Years Due to Pediatric Out-of-Hospital Cardiac Arrest in the United States: A CARES Surveillance Group Study.

BACKGROUND: Disability-adjusted life years (DALY) are a common public health metric used to estimate disease burden. The DALY due to pediatric out-of-hospital cardiac arrest (OHCA) in the United States is unknown. We aimed to estimate pediatric OHCA DALY and to compare it with the other leading causes of pediatric death and disability in the United States. METHODS: We conducted a retrospective observational analysis of the national Cardiac Arrest Registry to Enhance Survival database. DALY were calculated as the sum of years of life lost and years lived with disability. Years of life lost were calculated using all pediatric (age <18 years) nontraumatic OHCA from the Cardiac Arrest Registry to Enhance Survival from 2016 to 2020. Disability weights based on cerebral performance category scores, an outcome measure of neurologic function, were used to estimate years lived with disability . Data were reported as total, mean, and rate per 100 000 individuals, and were compared with the leading causes of pediatric DALY in the United States published by the Global Burden of Disease study for 2019. RESULTS: Totally 11 177 OHCA met the study inclusion criteria. A modest increase in total OHCA DALY in the United States was observed from 407 500 (years of life lost = 407 435 and years lived with disability =65) in 2016 to 415 113 (years of life lost = 415 055 and years lived with disability =58) in 2020. The DALY rate increased from 553.3 per 100 000 individuals in 2016 to 568.3 per 100 000 individuals in 2020. For 2019, OHCA was the 10th leading cause of pediatric DALY lost behind neonatal disorders, injuries, mental disorders, premature birth, musculoskeletal disorders, congenital birth defects, skin diseases, chronic respiratory diseases, and asthma. CONCLUSIONS: Nontraumatic OHCA is one of the top 10 leading causes of annual pediatric DALY lost in the United States.

Disability-Adjusted Life-Years After Adult In-Hospital Cardiac Arrest in the United States.

We sought to estimate disability-adjusted life-years (DALYs) because of adult in-hospital cardiac arrest (IHCA) and to compare IHCA DALY to other leading causes of death and disability in the United States. DALY were calculated as the sum of years of life lost and years lived with disability. The years of life lost were calculated using all adult IHCA with complete data from the American Heart Association Get With The Guidelines-Resuscitation database for 2015 to 2019. Cerebral performance category scores and published disability weights were used to estimate the years lived with disability for survivors. The cohort's DALY were extrapolated to a national level to estimate the total United States DALY and were compared with a published ranking of the leading causes of DALY in the United States for 2018. Data were reported as DALY total and rate per 100,000. A total of 99,897 IHCA were included from 329 hospitals. The total IHCA DALY increased from 2,208,310 in 2015 to 2,225,722 in 2019. A modest decrease in the DALY rate was observed from 689 per 100,000 in 2015 to 678 per 100,000 in 2019. In 2018, the rate of IHCA DALY were 728 per 100,000, which represented the 11th leading cause of DALY. When combined with out-of-hospital cardiac arrest (1,322 per 100,000), sudden cardiac arrest (2,050 per 100,000) was found the be the 2nd leading cause of DALY after ischemic heart disease (2,681 per 100,000) in 2018. In conclusion, adult IHCA is a leading cause of DALY in the United States and has increased over time because of the expansion of the Get With The Guidelines-Resuscitation database.

Feasibility and Acceptance of a Teletrauma Surgery Consult Service to Rural and Community Hospitals: A Pilot Study.

BACKGROUND: Many trauma patients currently transferred from rural and community hospitals (RCH) to Level I trauma centers (LITC) for trauma surgery evaluation may instead be appropriate for immediate discharge or admission to the local facility after evaluation by a trauma and acute care surgery (TACS) surgeon. Unnecessary use of resources occurs with current practice. We aimed to demonstrate the feasibility and acceptance of a teletrauma surgery consultation service between LITC and RCH. STUDY DESIGN: LITC TACS surgeons provided telehealth consults on trauma patients from 3 local RCHs. After consultation, appropriate patients were transferred to LITC; selected patients remained at or were discharged from RCH. Participating TACS surgeons and RCH physicians were surveyed. RESULTS: A total of 28 patients met inclusion criteria during the 5-month pilot phase, with 7 excluded due to workflow issues. The mean ± SD age was 63 ± 17 years. Of 21 patients, 7 had intracranial hemorrhage; 12 had rib fractures. The mean ± SD Injury Severity Score was 8.1 ± 4.0). A total of 6 patients were discharged from RCH, 4 admitted to RCH hospitalist service, 2 transferred to a LITC emergency room, and 9 transferred to LITC as direct admission. There was one 30-day readmission and no missed injuries or complications, or deaths. RCH providers were highly satisfied with the teletrauma surgery consultation service, TACS surgeons, and equipment used. Mental demand and effort of consulting TACS surgeons decreased significantly as the consult number increased. CONCLUSIONS: Teletrauma surgery consultation involving 3 RCH within our system is feasible and acceptable. A total of 10 transfers and 19 emergency department visits were avoided. There was favorable acceptance by RCH providers and TACS surgeons.

Estimating the impact of the COVID-19 pandemic on out-of-hospital cardiac arrest burden of disease in the United States.

Background: The impact of the COVID-19 pandemic on out-of-hospital cardiac arrest (OHCA) burden of disease in the United States is unknown. We sought to estimate and compare disability-adjusted life years (DALYs) lost because of OHCA during the COVID-19 pandemic to prepandemic values. Methods: DALY were calculated as the sum of years of life lost (YLL) and years lived with disability (YLD). Adult non-traumatic emergency medical services-treated OHCA from the Cardiac Arrest Registry to Enhance Survival database for 2016 to 2020 were used to estimate YLL. Cerebral performance category score disability weights were used to estimate YLD. The calculated DALY for the study population was extrapolated to a national level to estimate total US DALY. Data were reported as DALY total and rate. Data for 2020 (pandemic) were compared prepandemic years (2016-2019) via the chi-square test or t-test, as appropriate. Results: A total of 440,438 OHCA met study inclusion criteria. Total OHCA DALY in the United States increased from 4,468,155 (YLL = 4,463,988; YLD = 4167) in 2019 to 5,379,660 (YLL = 5,375,464; YLD = 4197) in 2020. The DALY rate increased from 1357 per 100,000 individuals in 2019 to 1630 per 100,000 individuals in 2020. Bystander cardiopulmonary resuscitation (CPR) rates did not significantly change (47.96% in 2016-2019 vs. 47.89% in 2020; p = 0.157). Conclusion: The overall burden of disease because of adult OHCA increased significantly during the COVID-19 pandemic. We observed no change in the willingness of layperson bystanders to perform CPR on a national level in the United States.

Annual and lifetime economic productivity loss due to adult out-of-hospital cardiac arrest in the United States: A study for the CARES Surveillance Group.

OBJECTIVE: To estimate the annual and lifetime economic productivity loss due to adult out-of-hospital cardiac arrest (OHCA) in the United States (U.S.). METHODS: All adult (age ≥ 18 years) non-traumatic EMS-treated OHCA with complete data for age, sex, race, and survival outcomes from the CARES database for 2013-2018 were included. Annual and lifetime labor productivity values, based on age and gender, were obtained from previously published national economic data. Productivity losses for OHCA events were calculated by year in U.S. dollars. Productivity losses for survivors were assigned by cerebral performance category score (CPC): CPC 1 and 2 = 0% productivity loss; CPC 3-5 = 100% productivity loss. Sensitivity analyses were performed assigning CPC 2 varying productivity losses (0-100%) based on CPC score and discharge location. Lifetime productivity values assumed 1% annual growth and 3% discount rate and were adjusted for inflation based on 2016 values. Results were extrapolated to annual U.S. population estimates for the study period. RESULTS: A total of 338,492 (96.5%) cases met inclusion criteria. The mean annual and lifetime productivity losses per OHCA in 2018 were $48,224 and $638,947 respectively. The total annual economic productivity loss due to OHCA in the U.S. increased from $7.4B in 2013 to $11.3B in 2018. Lifetime economic productivity loss increased from $95.2B in 2013 to $150.2B in 2018. Sensitivity analyses yielded similar findings. Per annual death, OHCA ranked third ($10.2B) in annual economic productivity loss in the U.S. behind cancer ($22.9B) and heart disease ($20.3B) in 2018. CONCLUSION: Adult non-traumatic OHCA events are associated with significant annual and lifetime economic productivity losses and should be the focus of public health resources to improve preventative measures and survival outcomes.

A Prospective Evaluation of Clinical HEART Score Agreement, Accuracy, and Adherence in Emergency Department Chest Pain Patients.

STUDY OBJECTIVE: The HEART score is a risk stratification aid that may safely reduce chest pain admissions for emergency department patients. However, differences in interpretation of subjective components potentially alters the performance of the score. We compared agreement between HEART scores determined during clinical practice with research-generated scores and estimated their accuracy in predicting 30-day major adverse cardiac events. METHODS: We prospectively enrolled adult ED patients with symptoms concerning for acute coronary syndrome at a single tertiary center. ED clinicians submitted their clinical HEART scores during the patient encounter. Researchers then independently interviewed patients to generate a research HEART score. Patients were followed by phone and chart review for major adverse cardiac events. Weighted kappa; unweighted Cohen's kappa; prevalence-adjusted, bias-adjusted kappa (PABAK); and test probabilities were calculated. RESULTS: From November 2016 to June 2019, 336 patients were enrolled, 261 (77.7%) were admitted, and 30 (8.9%) had major adverse cardiac events. Dichotomized HEART score agreement was 78% (kappa 0.48, 95% confidence interval [CI] 0.37 to 0.58; PABAK 0.57, 95% CI 0.48 to 0.65) with the lowest agreement in the history (72%; WK 0.14, 95% CI 0.06 to 0.22) and electrocardiogram (85%; WK 0.4, 95% CI 0.3 to 0.49) components. Compared with researchers, clinicians had 100% sensitivity (95% CI 88.4% to 100%) (versus 86.7%, 95% CI 69.3% to 96.2%) and 27.8% specificity (95% CI 22.8% to 33.2%) (versus 34.6%, 95% CI 29.3% to 40.3%) for major adverse cardiac events. Four participants with low research HEART scores had major adverse cardiac events. CONCLUSION: ED clinicians had only moderate agreement with research HEART scores. Combined with uncertainties regarding accuracy in predicting major adverse cardiac events, we urge caution in the widespread use of the HEART score as the sole determinant of ED disposition.

National Institutes of Health investment into cardiac arrest research: A study for the CARES Surveillance Group.

OBJECTIVE: To calculate and compare the National Institutes of Health (NIH) research investment for cardiac arrest (CA) to other leading causes of disability-adjusted life years (DALY) in the United States (U.S.). METHODS: A search within NIH RePORTER for 2017 was performed using single common resuscitation terms. Grants were individually reviewed and categorized as CA research (yes/no) using predefined criteria. DALY were calculated as the sum of years of life lost (YLL) and years lived with disability (YLD) using all adult non-traumatic out-of-hospital CA (OHCA) from the CARES database for 2017. Total DALY for the study population were extrapolated to a national level. Leading causes of DALY were obtained from the Global Burden of Disease study and funding data were extracted from the NIH Categorical Spending Report for comparison. The outcome measure was U.S. dollars invested per annual DALY. RESULTS: The search yielded 290 grants, of which 87 (30%) were classified as CA research. Total funding for CA research in 2017 was $37.1M. A total of 73,915 (97%) cases from CARES met study inclusion criteria for the DALY analysis. The total DALY following adult OHCA in the U.S. population were 4,335,949 (YLL 4,332,166, YLD 3784). Per annual DALY, the NIH invested $287 for diabetes, $92 for stroke, $55 for ischemic heart disease, and $9 for CA research. CONCLUSION: The NIH investment into CA research is far less than other comparable causes of death and disability in the U.S. These results should help inform utilization of limited resources to improve public health.

A prospective analysis of time to screen protocol ECGs in adult Emergency Department triage patients.

BACKGROUND: Early identification of ST elevation MI (STEMI) in emergency departments (ED) via electrocardiogram (ECG) expedites intervention. While screening of all ED chest pain ECGs should be obtained within 10 minutes per the American Heart Association, 40% of all ECGs are software-analyzed as "Normal" or "Otherwise Normal." However, the reliability of this analysis and the time for confirmation read are uncertain. This study investigates the time necessary for Patient Care Technicians (PCTs) to deliver ECGs to ED attendings to confirm automated interpretation. METHODS: A prospective cohort study was conducted at a single academic ED. All patients ≥18 years who had a triage ECG were included. ECGs were obtained within 10 min of arrival, time-stamped, delivered for ED attending review and time-stamped upon PCT return to triage. Data were entered into REDCap and analyzed using StatPlus. RESULTS: During the 4-month study, 1768 ECGs were collected. Distribution of automated readings was: "Normal ECG" 33.7%; "Otherwise Normal ECG" 11.2%; and "borderline/abnormal" 55.1%. The median time necessary for PCTs to confirm a screening ECG was 2.8 min (IQR 2,4) with attending physicians interrupted an average of 14.6 times per day. CONCLUSION: Screening of triage ECGs is time-intensive and compounds the frequency of physician interruptions. Although findings are not generalizable, the impact of these interruptions on patient care and safety is paramount and universal. Future directions include validating the reliability of "Normal" and "Otherwise Normal" ECG automated readings to obviate the need to interrupt ED physician for expedited screening confirmation.

Trend analysis of disability-adjusted life years following adult out-of-hospital cardiac arrest in the United States: A study from the CARES Surveillance Group.

AIM: To estimate and trend disability-adjusted life years (DALY) following adult out-of-hospital cardiac arrest (OHCA) over time, and to compare OHCA DALY to other leading causes of death and disability in the U.S. METHODS: DALY were calculated as the sum of years of life lost (YLL) and years lived with disability (YLD). Adult non-traumatic emergency medical services-treated OHCA from the Cardiac Arrest Registry to Enhance Survival (CARES) database for 2013-2018 were used to estimate YLL. Cerebral performance category score disability weights were used to estimate YLD. The calculated DALY for the study population was extrapolated to a national level to estimate total U.S. DALY. Data were reported as DALY total and rate. Data were compared to the top 10 causes of DALY in the U.S. RESULTS: 337,991 OHCA met study inclusion criteria. Total U.S. OHCA DALY increased from 3,005,308 in 2013 to 4,326,745 in 2018. The DALY rate increased from 950.9 per 100,000 individuals to 1322.4 per 100,000 individuals. OHCA DALY ranked fifth in the U.S. behind ischemic heart disease (2470), drug use disorders (1703), chronic obstructive pulmonary disease (1449), and back pain (1336). OHCA represented the largest percent increase in DALY rate (40.3%) over the study period. CONCLUSION: Adult non-traumatic OHCA is a leading cause of DALY in the U.S. and the burden of disease due to OHCA has increased rapidly over time. These findings are likely due to more precise national OHCA surveillance, and suggest that the public health impact of OHCA is larger than previously described.

The association between scene time interval and neurologic outcome following adult bystander witnessed out-of-hospital cardiac arrest.

OBJECTIVE: To analyze the association between Emergency Medical Services (EMS) scene time interval (STI) and survival with functional neurologic recovery following adult out-of-hospital cardiac arrest (OHCA). METHODS: A retrospective analysis of prospectively collected data from the national Cardiac Arrest Registry to Enhance Survival from January 2013 to December 2018. All adult non-traumatic, EMS-treated, bystander-witnessed OHCA with complete data were included. Patients with STI times >60 min, defined as the time from EMS arrival at the patient's side to the time the transport vehicle left the scene, unwitnessed OHCA, nursing home events, EMS-witnessed OHCA, or patients with termination of resuscitation in the field were excluded. The primary outcome was survival with functional recovery (Cerebral Performance Category [CPC] = 1 or 2). Multivariable logistic regression was used to quantify the association of STI with the primary. RESULTS: 67,237 patients met inclusion criteria with 12,098 (18.0%) surviving with functional recovery. Mean STI (SD) for survivors with CPC 1 or 2 was 19 (8.4) and 22.8 (10.5) for those with poor outcomes (death or CPC 3-4; p < 0.001). For every 1-min increase in STI, the adjusted odds of a poor outcome increased by 3.5%; odds ratio = 1.035; 95% CI (1.027, 1.044); p < 0.001. Restricted cubic spline analysis showed increased risk of poor outcome after approximately 20 min. CONCLUSION: Longer STI times are strongly associated with poor neurologic outcome in bystander-witnessed OHCA patients. After a STI duration of approximately 20 min, the associated risk of a poor neurologic outcome increased more rapidly.

Predicting Outcome After Out-of-Hospital Cardiac Arrest: Lactate, Need for Vasopressors, and Cytochrome c.

BACKGROUND: Outcome prediction after out-of-hospital cardiac arrest (OHCA) is difficult. We hypothesized that lactate and need for vasopressors would predict outcome, and that addition of a mitochondrial biomarker would enhance performance of the tool. METHODS: Prospective observational study of OHCA patients presenting to an academic medical center September 2008 to April 2016. We conducted univariate and multivariate logistic regressions. RESULTS: Patients were divided based on 2 variables: vasopressor status and initial lactate (<5 mmol/L, 5-10, ≥10). Three hundred fifty-two patients were evaluated; 249 had a lactate within 3 hours and were included. Patients on vasopressors had higher mortality (74% vs 40%; P < .001). A stepwise increase in mortality is associated with increasing lactate (45% lactate <5, 66% 5-10, and 83% ≥10; P < 001). Multivariable models with lactate group and vasopressors as predictors demonstrated excellent discrimination (area under the receiver operating curve [AUC]: 0.73 [95% confidence interval, CI: 0.66-0.79]; adjusted for additional covariates: AUC: 0.81 [95% CI: 0.75-0.86]). Thirty-six patients had cytochrome c levels available; among these 36, when comparing models with and without cytochrome c, there was no difference (AUC: 0.88 [95% CI: 0.76-1.00] vs AUC: 0.85 [95% CI: 0.73-0.98], respectively; P = .30). CONCLUSION: In this prospective validation, the combination of lactate and vasopressors in the immediate postarrest period is predictive of mortality. Cytochrome c offered minimal additional predictive power.