Association between bystander intervention and emergency medical services and the return of spontaneous circulation in out-of-hospital cardiac arrests occurring at a train station in the Tokyo metropolitan area: A retrospective cohort study.

Aim: The purpose of this study was to stratify patients who achieved return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA) with bystander procedures pre-emergency medical service (EMS) arrival and those who achieved ROSC with procedures post-EMS arrival, compare outcomes at 1-month, and identify factors associated with pre-EMS-arrival-ROSC. Methods: A retrospective cohort analysis of OHCAs occurring at stations in the Tokyo metropolitan area between 2014 and 2018 was conducted. Subjects were stratified by ROSC phase (categorized as pre- and post-EMS arrival and non-ROSC). Survival at 1-month post-OHCA and the percentage of favourable neurological function in each ROSC phase were analysed. In addition, factors associated with Pre-EMS-arrival-ROSC were identified using multivariable logistic regression analysis. The time of occurrence of OHCA was classified into four-time categories as follows. Rush hour on morning [7:00-9:00], Rush hour on evening [17:00-21:00], Daytime [9:00-17:00], and Night or Early morning [21:00-7:00]. Results: Among the 63,089 OHCA in the dataset, 702 were analysed. At 1-month after OHCA occurrence, Pre-EMS-arrival ROSC had higher survival rates than post-EMS-arrival ROSC (86.8% vs. 54.1%) and CPC1-2 rates (73.6% vs. 38.5%). Pre-EMS-arrival ROSC was associated (adjusted odds ratio [95% confidence interval]) with non-older-adult patients (1.59 [1.05-2.43]), witnessed OHCA (1.82 [1.03-3.31]), evening rush-hour (17:00-21:00; 2.08 [1.05-4.11]), conventional CPR (33.42 [7.82-868.44]), hands-only CPR (17.06 [4.30-436.48]), bystander defibrillation performed once (3.31 [1.59-6.99]). Conclusions: In an OHCA at a station in Tokyo, ROSC achieved with bystander treatment alone had a better outcome at 1-month compared to ROSC with EMS intervention.

The association of delayed advanced airway management and neurological outcome after out-of-hospital cardiac arrest in Japan.

INTRODUCTION: The effectiveness of advanced airway management (AAM) for out-of-hospital cardiac arrest (OHCA) has been reported differently in each region; however, no study has accounted for the regional differences in the association between the timing of AAM implementation and neurological outcomes. OBJECTIVE: This study aimed to evaluate the association between the timing of patient or prefecture level AAM and a favorableneurological outcome defined by cerebral performance category 1 or 2 (CPC 1-2). METHODS: A retrospective cohort study was conducted using data from the All-Japan Utstein Registry between 2013 and 2017. We included patients aged ≥8 years with OHCA for whom AAM (i.e., supraglottic airway or endotracheal intubation) was performed in a prehospital setting (n = 182,913). We divided the patients into shockable (n = 11,740) and non-shockable (n = 171,173) cohorts based on the initial electrocardiogram rhythm. Multilevel logistic regression analysis estimated the association between AAM time (patient contact-to-AAM performance interval) at the patient level (1-min unit increments), prefecture level (> 9.2 min vs. ≤ 9.2 min) and CPC 1-2. RESULTS: A delay in AAM time was negatively associated with CPC 1-2 (adjusted odds ratio [AOR], 0.92, 0.96; 95% confidence interval [CI], 0.90-0.93, 0.95-0.97, respectively), regardless of initial rhythm. At the prefecture level, a delay in AAM time was negatively associated with CPC 1-2 (AOR, 0.77, 0.68; 95% CI, 0.58-1.04, 0.50-0.94, respectively) only in the non-shockable cohort. CONCLUSION: A delay in AAM performance was negatively associated with CPC 1-2 in both shockable and non-shockable cohorts. Moreover, a delay in AAM performance at the prefecture level was negatively associated with CPC 1-2 in the non-shockable cohort.

Prehospital interventions and neurological outcomes in marathon-related sudden cardiac arrest using a rapid mobile automated external defibrillator system in Japan: a prospective observational study.

OBJECTIVE: To describe neurological outcomes after sudden cardiac arrests (SCAs) in road and long-distance races using a rapid mobile automated external defibrillator system (RMAEDS) intervention. METHODS: A total of 42 SCAs from 3 214 701 runners in 334 road and long-distance races from 1 February 2007 to 29 February 2020 were examined. Demographics, SCA interventions, EMS-related data and SCA-related outcomes were measured. Primary endpoints were favourable neurological outcomes (Cerebral Performance Categories 1-2) at 1-month and 1-year post-SCA. Secondary endpoints were factors related to the field return of spontaneous circulation (ROSC) and resuscitation characteristics, including the initial ECG waveform classification and resuscitation sequence times according to the initial ECG rhythm. RESULTS: The SCA incidence rate was 1.31 per 100 000 runners (age: median (IQR), 51 (36.5, 58.3) years). Field ROSC and full neurological recovery at 1-month post-SCA was achieved 90.4% and 92.9% of cases, respectively. In 22 cases in which bystander cardiopulmonary resuscitation was initiated within 1 min and defibrillation performed within 3 min, full neurological recovery was achieved at 1-month and 1-year post-SCA in 95.5.% and 95.5% of cases, respectively. CONCLUSIONS: The RMAEDS successfully treated patients with SCA during road and long-distance races yielding a high survival rate and favourable neurological outcomes. These findings support rapid intervention and the proper placement of healthcare teams along the race course to initiate chest compressions within 1 min and perform defibrillation within 3 min.

Early endotracheal intubation improves neurological outcome following witnessed out-of-hospital cardiac arrest in Japan: a population-based observational study.

AIM: It is unclear whether endotracheal intubation in the prehospital setting improves outcomes following out-of-hospital cardiac arrest. The purpose of this study was to evaluate the association between endotracheal intubation time (time from patient contact to endotracheal intubation) and favorable neurological outcomes on out-of-hospital cardiac arrest. METHODS: We extracted patients who underwent endotracheal intubation on the scene from a nationwide out-of-hospital cardiac arrest database registered between 2014 and 2017 in Japan. We included 14,969 witnessed and intubated adult out-of-hospital cardiac arrest cases. Patients were divided into Shockable (n = 1,102) and Non-shockable (n = 13,867) cohorts. We first drew the logistic curve due to predicting the association between endotracheal intubation time and favorable neurological outcome defined as Cerebral Performance Category (CPC) 1 or 2. Secondary, multivariable logistic regressions were used to estimate the association between the endotracheal intubation time (1-min unit increase), CPC 1 or 2. RESULTS: The logistic curve for CPC 1 or 2 showed similar shapes and indicated a decreasing outcome over time. From the results of multivariable logistic regression, in the Shockable cohort, endotracheal intubation time delay was correlated with decreasing favorable outcomes: CPC 1 or 2 (adjusted odds ratio, 0.89; 95% confidence interval, 0.82-0.87). Results were the same for the Non-shockable cohort: CPC 1 or 2 (adjusted odds ratio, 0.94; 95% confidence interval, 0.89-0.99). CONCLUSION: Early endotracheal intubation was correlated with favorable neurological outcome. Training for intubation skills and improving protocols are needed for carrying out early endotracheal intubation.

A pilot study of Practice While Watch based 50 min school quality cardiopulmonary resuscitation classroom training: a cluster randomized control trial.

AIM: Cardiopulmonary resuscitation (CPR) training in schools can increase the rate of bystander CPR. We assessed whether a "Quality CPR (QCPR) Classroom" can support CPR performance by students trained by a teacher who is not a CPR instructor. METHODS: A cluster randomized trial was undertaken to assess the effectiveness of a 50-min Practice While Watch CPR training program enhanced by QCPR Classroom, which used 42 manikins connected by Bluetooth to real-time feedback monitoring. Fifty-seven students were divided into Group 1, taught by a non-CPR-instructor, and Group 2, taught by a CPR instructor. Psychomotor and cognitive tests were administered before and after training. Primary outcomes were post-training compression depth and rate and percent of improvement in adequate depth, recoil, and overall score. The secondary outcome was risk improvement. RESULTS: Post-training, Group 1 achieved 62.1 ± 7.7 mm and 118.0 ± 3.6 compressions/min whereas Group 2 achieved 57.4 ± 9.8 mm and 119.8 ± 5.4 compressions/min. The overall score improvement in percentage points was 36.4 ± 25.9% and 27.0 ± 27.7%, respectively (P ≤ 0.001 for both). The adequate depth improvement in percentage points was 22.4 ± 35.4% and 32.5 ± 40.0%, respectively (P = 0.33). Teaching by a non-CPR instructor improved student cognitive knowledge. CONCLUSIONS: Using a QCPR Classroom to enhance CPR teaching by a non-CPR-instructor results in similar or better outcomes compared to using a CPR instructor. Use of a Practice While Watch QCPR Classroom will provide adequate quality in preparing students for CPR.

Effect of real-time visual feedback device 'Quality Cardiopulmonary Resuscitation (QCPR) Classroom' with a metronome sound on layperson CPR training in Japan: a cluster randomized control trial.

OBJECTIVES: 'Quality Cardiopulmonary Resuscitation (QCPR) Classroom' was recently introduced to provide higher-quality Cardiopulmonary Resuscitation (CPR) training. This study aimed to examine whether novel QCPR Classroom training can lead to higher chest-compression quality than standard CPR training. DESIGN: A cluster randomised controlled trial was conducted to compare standard CPR training (control) and QCPR Classroom (intervention). SETTING: Layperson CPR training in Japan. PARTICIPANTS: Six hundred forty-two people aged over 15 years were recruited from among CPR trainees. INTERVENTIONS: CPR performance data were registered without feedback on instrumented Little Anne prototypes for 1 min pretraining and post-training. A large classroom was used in which QCPR Classroom participants could see their CPR performance on a big screen at the front; the control group only received instructor's subjective feedback. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcomes were compression depth (mm), rate (compressions per minute (cpm)), percentage of adequate depth (%) and recoil (%). Survey scores were a secondary outcome. The survey included participants' confidence regarding CPR parameters and ease of understanding instructor feedback. RESULTS: In total, 259 and 238 people in the control and QCPR Classroom groups, respectively, were eligible for analysis. After training, the mean compression depth and rate were 56.1±9.8 mm and 119.2±7.3 cpm in the control group and 59.5±7.9 mm and 116.8±5.5 cpm in the QCPR Classroom group. The QCPR Classroom group showed significantly more adequate depth than the control group (p=0.001). There were 39.0% (95% CI 33.8 to 44.2; p<0.0001) and 20.0% improvements (95% CI 15.4 to 24.7; P<0.0001) in the QCPR Classroom and control groups, respectively. The difference in adequate recoil between pretraining and post-training was 2.7% (95% CI -1.7 to 7.1; pre 64.2±36.5% vs post 66.9%±34.6%; p=0.23) and 22.6% in the control and QCPR Classroom groups (95% CI 17.8 to 27.3; pre 64.8±37.5% vs post 87.4%±22.9%; p<0.0001), respectively. CONCLUSIONS: QCPR Classroom helped students achieve high-quality CPR training, especially for proper compression depth and full recoil. For good educational achievement, a novel QCPR Classroom with a metronome sound is recommended.

Does dispatcher-assisted CPR generate the same outcomes as spontaneously delivered bystander CPR in Japan?

AIM: We investigated whether DA-CPR would have the same effect as spontaneously-delivered bystander CPR. METHODS: A total of 37,899 witnessed cardiogenic out of hospital cardiac arrest (OHCA) selected from a nationwide Utstein-Japanese database between 2008 and 2012. Patients were divided into four groups as follows: CPR initiated with dispatcher assistance (DA-CPR; n=10,424), no CPR provided with dispatcher assistance (DA-No CPR; n=4658), spontaneously-delivered bystander CPR provided without DA (BCPR; n=6630), and both BCPR and dispatcher assistance was not provided (No BCPR-No DA; n=16,187). The primary endpoint was rate of shockable rhythm on the initial ECG, return of spontaneous circulation (ROSC) on the field. A multivariable logistic regression analysis was used. Adjusted odds ratios (AOR) are presented as 95% confidence intervals (95% CIs) among the groups. RESULTS: The rate of DA-CPR implementation has gradually increased since 2005. In comparison with DA-No CPR, both spontaneously-delivered BCPR and DA-CPR were significantly associated with the following factors: increased rate of shockable rhythm on the initial ECG (AOR, 1.75 and 1.72; 95% CI, 1.67 to 1.85 and 1.63 to 1.83),improved field ROSC (AOR, 1.42 and 1.40; 95% CI, 1.33 to 1.52 and 1.30 to 1.51) and 1-month favorable neurological outcomes (AOR, 1.72 and 1.80; 95% CI, 1.59 to 1.88 and 1.64 to 1.97), respectively. CONCLUSIONS: We found that the spontaneously delivered BCPR group showed favorable results. In comparison to the DA-No BCPR group, DA-CPR group resulted in the nearly equivalent effect as spontaneously-delivered BCPR group. Further standard dispatcher education is indicated.

The influence of excluding patients with bystander return of spontaneous circulation in the current OHCA database.

BACKGROUND: The effect of bystander interventions has been extensively evaluated by cerebral function after 1 month post-resuscitation. However, patients who received bystander cardiopulmonary resuscitation (BCPR) and achieved the return of spontaneous circulation (ROSC) before the arrival of the emergency medical system (EMS) are routinely defined with an unknown electrocardiogram (ECG) and are usually excluded before analysis. The aim is to determine the influence of excluding patients with unknown first monitored rhythm, which includes cases of bystander ROSC, from the out-of-hospital cardiac arrest (OHCA) database. METHODS: This nationwide population-based observational study was conducted in Japan using Utstein data from 2011 to 2014. In total, 91,995 patients with bystander-witnessed cardiogenic OHCA received resuscitation attempts in the pre-hospital setting. These patients were divided into three groups by the first monitored rhythm upon EMS arrival. We analysed the differences of datasets that included and excluded the unknown group and determined the effect on outcomes by multivariate logistic regression and odds ratios (ORs) with 95% confidence intervals (95% CIs). RESULTS: When the unknown group was excluded from the data, the adjusted odds ratio (AOR) of cardiopulmonary resuscitation (CPR) to favourable cerebral performance category (CPC) 1 or 2 was decreased (conventional CPR: AOR, 1.90 to 1.58; chest-compression-only CPR: AOR, 2.08 to 1.69) compared to the unknown group's inclusion. Conversely, the AOR of public-access defibrillation (PAD) was increased (AOR, 4.51 to 6.13). CONCLUSIONS: The exclusion of unknown ECGs from a dataset may lose ROSC patients by bystander CPR, causing selection bias to affect outcomes.

Effectiveness of cadaver-based educational seminar for trauma surgery: skills retention after half-year follow-up.

Aim: In Japan, trauma surgery training remains insufficient, and on-the-job training has become increasingly difficult because of the decreasing number of severe trauma patients and the development of non-operative management. Therefore, we assessed whether a 1-day cadaver-based seminar is effective for trauma surgery training. Methods: Data were collected from 11 seminars carried out from January 2013 to March 2014, including a 10-point self-assessment of confidence levels (SACL) for 21 surgical skills and an evaluation of the contents before, just after, and a half-year after the seminar. Statistical analysis was undertaken using the paired t-test at P < 0.0167. Results: A total of 135 participants were divided into three groups based on experience and clinical careers. The SACL improved in all skills between before and just after the seminar, however, they decreased between just after and a half-year after the seminar. The SACL did not change significantly in all skills between just after and a half-year after the seminar in highly experienced and experienced group members belonging to an emergency center. Conclusions: A cadaver-based seminar provided more self-confidence just after the seminar for participants at all experience levels. This effect was not maintained after a half-year, except in participants who can practice the skills at an emergency center. Practicing and participating in the seminar repeatedly is suggested to be effective for skills retention in trauma surgery.