Predicting Out-of-Hospital Cardiac Arrest in the General Population Using Electronic Health Records.

BACKGROUND: The majority of out-of-hospital cardiac arrests (OHCAs) occur among individuals in the general population, for whom there is no established strategy to identify risk. In this study, we assess the use of electronic health record (EHR) data to identify OHCA in the general population and define salient factors contributing to OHCA risk. METHODS: The analytical cohort included 2366 individuals with OHCA and 23 660 age- and sex-matched controls receiving health care at the University of Washington. Comorbidities, electrocardiographic measures, vital signs, and medication prescription were abstracted from the EHR. The primary outcome was OHCA. Secondary outcomes included shockable and nonshockable OHCA. Model performance including area under the receiver operating characteristic curve and positive predictive value were assessed and adjusted for observed rate of OHCA across the health system. RESULTS: There were significant differences in demographic characteristics, vital signs, electrocardiographic measures, comorbidities, and medication distribution between individuals with OHCA and controls. In external validation, discrimination in machine learning models (area under the receiver operating characteristic curve 0.80-0.85) was superior to a baseline model with conventional cardiovascular risk factors (area under the receiver operating characteristic curve 0.66). At a specificity threshold of 99%, correcting for baseline OHCA incidence across the health system, positive predictive value was 2.5% to 3.1% in machine learning models compared with 0.8% for the baseline model. Longer corrected QT interval, substance abuse disorder, fluid and electrolyte disorder, alcohol abuse, and higher heart rate were identified as salient predictors of OHCA risk across all machine learning models. Established cardiovascular risk factors retained predictive importance for shockable OHCA, but demographic characteristics (minority race, single marital status) and noncardiovascular comorbidities (substance abuse disorder) also contributed to risk prediction. For nonshockable OHCA, a range of salient predictors, including comorbidities, habits, vital signs, demographic characteristics, and electrocardiographic measures, were identified. CONCLUSIONS: In a population-based case-control study, machine learning models incorporating readily available EHR data showed reasonable discrimination and risk enrichment for OHCA in the general population. Salient factors associated with OCHA risk were myriad across the cardiovascular and noncardiovascular spectrum. Public health and tailored strategies for OHCA prediction and prevention will require incorporation of this complexity.

Prehospital Administration of Norepinephrine and Epinephrine for Shock after Resuscitation from Cardiac Arrest.

INTRODUCTION: Shock after resuscitation from out-of-hospital cardiac arrest (OHCA) is often treated with vasopressors. We examined whether infusion of epinephrine versus norepinephrine was associated with prehospital rearrest and neurologically favorable survival among OHCA patients. METHODS: This retrospective study included OHCA cases in Seattle, Washington from 2014-2021 who had return of spontaneous circulation (ROSC) followed by vasopressor infusion. Our primary exposure was infusion of epinephrine or norepinephrine. Our primary outcome was prehospital rearrest. Secondary outcomes included survival and neurologically favorable outcome (Cerebral Performance Category score of 1 or 2). We used multivariable logistic regression to test associations between exposures and outcomes adjusting for key covariates. RESULTS: Of 451 OHCA patients with ROSC followed by vasopressor infusion, 253 (56%) received norepinephrine and 198 (44%) received epinephrine infusions. Those who received epinephrine were older (median 66 [interquartile ranges {IQR} 53-79] vs 63 [IQR 47-75] years), but otherwise had similar baseline characteristics. Patients who received epinephrine were twice as likely to rearrest (55% vs 25%). After adjustment, the difference in rearrest rates between epinephrine and norepinephrine persisted (OR 3.28, 95%CI 2.25-5.08), and the odds of pulses at hospital arrival were lower in the epinephrine group (OR 0.52 95%CI 0.32-0.83). After adjustment, there was no difference in neurologically favorable survival, survival to hospital admission, or survival to discharge. CONCLUSION: Patients who received epinephrine infusions after ROSC suffered prehospital rearrest more frequently than those who received norepinephrine. Survival and neurological status at hospital discharge were similar. Future trials should examine the optimal approach to hemodynamic management for post-OHCA shock.

Epidemiology of Covid-19 in a Long-Term Care Facility in King County, Washington.

BACKGROUND: Long-term care facilities are high-risk settings for severe outcomes from outbreaks of Covid-19, owing to both the advanced age and frequent chronic underlying health conditions of the residents and the movement of health care personnel among facilities in a region. METHODS: After identification on February 28, 2020, of a confirmed case of Covid-19 in a skilled nursing facility in King County, Washington, Public Health-Seattle and King County, aided by the Centers for Disease Control and Prevention, launched a case investigation, contact tracing, quarantine of exposed persons, isolation of confirmed and suspected cases, and on-site enhancement of infection prevention and control. RESULTS: As of March 18, a total of 167 confirmed cases of Covid-19 affecting 101 residents, 50 health care personnel, and 16 visitors were found to be epidemiologically linked to the facility. Most cases among residents included respiratory illness consistent with Covid-19; however, in 7 residents no symptoms were documented. Hospitalization rates for facility residents, visitors, and staff were 54.5%, 50.0%, and 6.0%, respectively. The case fatality rate for residents was 33.7% (34 of 101). As of March 18, a total of 30 long-term care facilities with at least one confirmed case of Covid-19 had been identified in King County. CONCLUSIONS: In the context of rapidly escalating Covid-19 outbreaks, proactive steps by long-term care facilities to identify and exclude potentially infected staff and visitors, actively monitor for potentially infected patients, and implement appropriate infection prevention and control measures are needed to prevent the introduction of Covid-19.

Comparison of Intubating Conditions with Succinylcholine Versus Rocuronium in the Prehospital Setting.

OBJECTIVE: Rapid sequence intubation (RSI) is frequently performed by emergency medical services (EMS). We investigated the relationship between succinylcholine and rocuronium use and time until first laryngoscopy attempt, first-pass success, and Cormack-Lehane (CL) grades. METHODS: We included adult patients for whom prehospital RSI was attempted from July 2015 through June 2022 in a retrospective, observational study with pre-post analysis. Timing was verified using recorded defibrillator audio in addition to review of continuous ECG, pulse oximetry, and end-tidal carbon dioxide waveforms. Our primary exposure was neuromuscular blocking agent (NMBA) used, either rocuronium or succinylcholine. Our prespecified primary outcome was the first attempt Cormack-Lehane view. Key secondary outcomes were first laryngoscopy attempt success rate, timing from NMBA administration to first attempt, number of attempts, and hypoxemic events. RESULTS: Of 5,179 patients in the EMS airway registry, 1,475 adults received an NMBA while not in cardiac arrest. Cormack-Lehane grades for succinylcholine and rocuronium were similar: grade I (64%, 59% [95% CI 0.64-1.09]), grade II (16%, 21%), grade III (18%, 16%), grade IV (3%, 3%). The median interval from NMBA administration to start of the first attempt was 57 s for succinylcholine and 83 s for rocuronium (mean difference 28 [95% CI 20-36] seconds). First attempt success was 84% for succinylcholine and 83% for rocuronium. Hypoxemic events were present in 25% of succinylcholine cases and 23% of rocuronium cases. CONCLUSIONS: Prehospital use of either rocuronium or succinylcholine is associated with similar Cormack-Lehane grades, first-pass success rates, and rates of peri-intubation hypoxemia.

Providing whole blood for an urban paramedical ambulance system.

INTRODUCTION: Hemorrhage is the second leading cause of death among urban trauma patients, and the provision of prehospital blood-based resuscitation can be lifesaving. We developed an efficient system to support blood-based resuscitation by an urban advanced life support ambulance system. METHODS: We worked with our state health department for permission for fire department paramedics to initiate blood transfusion and built protocols for field whole blood resuscitation. Our regional trauma center transfusion service provided 2 units of O positive, low-titer, leukoreduced whole blood in an internally monitored and sealed ice box weighing 10 pounds to the fire department paramedic supervisor. When notified, the supervisor transported the blood to the sites of anticipated need. Total blood use and wastage were recorded. RESULTS: Following two public hearings, we obtained state-wide approval for the initiation of emergency uncrossmatched blood transfusion by paramedics. Over a 1-year period beginning August 27, 2019, 160 units of whole blood were made available for use, and 51 units were transfused to 39 patients, 30 of whom were trauma patients. Other recipients include patients in shock from massive gastrointestinal, peripartum, or other suspected bleeding. Unused units were returned to the providing transfusion service after 1 week and used for hospital patient care without loss. The estimated cost of providing blood per mission was $0.28 and per patient transfused was $1138. CONCLUSIONS: With appropriate attention to detail, it is possible to provide whole blood to an urban paramedical ambulance system with efficient blood component usage, minimal blood wastage, and low cost.

Risk for Acquiring Coronavirus Disease Illness among Emergency Medical Service Personnel Exposed to Aerosol-Generating Procedures.

We investigated the risk of coronavirus disease (COVID-19)- patients transmitting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to emergency medical service (EMS) providers, stratified by aerosol-generating procedures (AGP), in King County, Washington, USA, during February 16-July 31, 2020. We conducted a retrospective cohort investigation using a statewide COVID-19 registry and identified 1,115 encounters, 182 with ≥1 AGP. Overall, COVID-19 incidence among EMS personnel was 0.57 infections/10,000 person-days. Incidence per 10,000 person-days did not differ whether or not infection was attributed to a COVID-19 patient encounter (0.28 vs. 0.59; p>0.05). The 1 case attributed to a COVID-19 patient encounter occurred within an at-risk period and involved an AGP. We observed a very low risk for COVID-19 infection attributable to patient encounters among EMS first responders, supporting clinical strategies that maintain established practices for treating patients in emergency conditions.

The Covid-19 Pandemic: Lessons Learned for Sustained Trauma Preparedness and Responses.

The emergence of coronavirus disease 2019 (COVID-19) that is caused by the SARS-CoV-2 virus has led to an overwhelming strain on healthcare delivery. This pandemic has created a sustained stress on the modern healthcare system, with unforeseen and potential drastic effects. Although the initial focus during this pandemic has been preparedness and response directed to the pandemic itself, traumatic injury has continued to remain a common problem that requires immediate evaluation and care to provide optimal outcomes. The State of Washington had the first reported case and death related to COVID-19 in the United States. Harborview Medical Center, which serves as the sole Level-1 adult and pediatric trauma center for the state, was rapidly affected by COVID-19, but still needed to maintain preparedness and responses to injured patients for the region. Although initially the focus was on the emerging pandemic on institutional factors, it became obvious that sustained efforts for regional trauma care required a more global focus. Because of these factors, Harborview Medical Center was quickly entrusted to serve as the coordinating center for the regions COVID-19 response, while also continuing to provide optimal care for injured patients during the pandemic. This response allowed the care of injured patients to be maintained within designated trauma centers during this pandemic. This present report summarizes the evolution of trauma care delivery during the first phase of this pandemic and provides informative recommendations for sustained responses to the care of injured patients during the pandemic based on lessons learned during the initial response.

Routine Use of a Bougie Improves First-Attempt Intubation Success in the Out-of-Hospital Setting.

STUDY OBJECTIVE: The bougie is typically treated as a rescue device for difficult airways. We evaluate whether first-attempt success rate during paramedic intubation in the out-of-hospital setting changed with routine use of a bougie. METHODS: A prospective, observational, pre-post study design was used to compare first-attempt success rate during out-of-hospital intubation with direct laryngoscopy for patients intubated 18 months before and 18 months after a protocol change that directed the use of the bougie on the first intubation attempt. We included all patients with a paramedic-performed intubation attempt. Logistic regression was used to examine the association between routine bougie use and first-attempt success rate. RESULTS: Paramedics attempted intubation in 823 patients during the control period and 771 during the bougie period. The first-attempt success rate increased from 70% to 77% (difference 7.0% [95% confidence interval 3% to 11%]). Higher first-attempt success rate was observed during the bougie period across Cormack-Lehane grades, with rates of 91%, 60%, 27%, and 6% for Cormack-Lehane grade 1, 2, 3, and 4 views, respectively, during the control period and 96%, 85%, 50%, and 14%, respectively, during the bougie period. Intubation during the bougie period was independently associated with higher first-attempt success rate (adjusted odds ratio 2.82 [95% confidence interval 1.96 to 4.01]). CONCLUSION: Routine out-of-hospital use of the bougie during direct laryngoscopy was associated with increased first-attempt intubation success rate.

Effect of Out-of-Hospital Sodium Nitrite on Survival to Hospital Admission After Cardiac Arrest: A Randomized Clinical Trial.

Importance: Therapeutic delivery of sodium nitrite during resuscitation improved survival in animal models of cardiac arrest, but efficacy has not been evaluated in clinical trials in humans. Objective: To determine whether parenteral administration of sodium nitrite given by paramedics during resuscitation for out-of-hospital cardiac arrest improved survival to hospital admission. Design, Setting, and Participants: Double-blind, placebo-controlled, phase 2 randomized clinical trial including 1502 adults in King County, Washington, with out-of-hospital cardiac arrest from ventricular fibrillation or nonventricular fibrillation. Patients underwent resuscitation by paramedics and were enrolled between February 8, 2018, and August 19, 2019; follow-up and data abstraction were completed by December 31, 2019. Interventions: Eligible patients with out-of-hospital cardiac arrest were randomized (1:1:1) to receive 45 mg of sodium nitrite (n = 500), 60 mg of sodium nitrite (n = 498), or placebo (n = 499), which was given via bolus injection by the paramedics as soon as possible during active resuscitation. Main Outcomes and Measures: The primary outcome was survival to hospital admission and was evaluated with 1-sided hypothesis testing. The secondary outcomes included out-of-hospital variables (rate of return of spontaneous circulation, rate of rearrest, and use of norepinephrine to support blood pressure) and in-hospital variables (survival to hospital discharge; neurological outcomes at hospital discharge; cumulative survival to 24 hours, 48 hours, and 72 hours; and number of days in the intensive care unit). Results: Among 1502 patients with out-of-hospital cardiac arrest who were randomized (mean age, 64 years [SD, 17 years]; 34% were women), 99% completed the trial. Overall, 205 patients (41%) in the 45 mg of sodium nitrite group and 212 patients (43%) in the 60 mg of sodium nitrite group compared with 218 patients (44%) in the placebo group survived to hospital admission; the mean difference for the 45-mg dose vs placebo was -2.9% (1-sided 95% CI, -8.0% to ∞; P = .82) and the mean difference for the 60-mg dose vs placebo was -1.3% (1-sided 95% CI, -6.5% to ∞; P = .66). None of the 7 prespecified secondary outcomes were significantly different, including survival to hospital discharge for 66 patients (13.2%) in the 45 mg of sodium nitrite group and 72 patients (14.5%) in the 60 mg of sodium nitrite group compared with 74 patients (14.9%) in the placebo group; the mean difference for the 45-mg dose vs placebo was -1.7% (2-sided 95% CI, -6.0% to 2.6%; P = .44) and the mean difference for the 60-mg dose vs placebo was -0.4% (2-sided 95% CI, -4.9% to 4.0%; P = .85). Conclusions and Relevance: Among patients with out-of-hospital cardiac arrest, administration of sodium nitrite, compared with placebo, did not significantly improve survival to hospital admission. These findings do not support the use of sodium nitrite during resuscitation from out-of-hospital cardiac arrest. Trial Registration: ClinicalTrials.gov Identifier: NCT03452917.

Targeted Temperature Management at 33 Versus 36 Degrees: A Retrospective Cohort Study.

OBJECTIVES: To determine the association between targeted temperature management goal temperature of 33°C versus 36°C and neurologic outcome after out-of-hospital cardiac arrest. DESIGN: This was a retrospective, before-and-after, cohort study. SETTING: Urban, academic, level 1 trauma center from 2010 to 2017. PATIENTS: Adults with nontraumatic out-of-hospital cardiac arrest who received targeted temperature management. INTERVENTIONS: Our primary exposure was targeted temperature management goal temperature, which was changed from 33°C to 36°C in April of 2014 at the study hospital. Primary outcome was neurologically intact survival to discharge. Secondary outcomes included hospital mortality and care processes. MEASUREMENTS AND MAIN RESULTS: Of 782 out-of-hospital cardiac arrest patients transported to the study hospital, 453 (58%) received targeted temperature management. Of these, 258 (57%) were treated during the 33°C period (targeted temperature management 33°C) and 195 (43%) were treated during the 36°C period (targeted temperature management 36°C). Patients treated during targeted temperature management 33°C were older (57 vs 52 yr; p < 0.05) and had more arrests of cardiac etiology (45% vs 35%; p < 0.05), but otherwise had similar baseline characteristics, including initial cardiac rhythm. A total of 40% of patients treated during targeted temperature management 33°C survived with favorable neurologic outcome, compared with 30% in the targeted temperature management 36°C group (p < 0.05). After adjustment for demographic and cardiac arrest characteristics, targeted temperature management 33°C was associated with increased odds of neurologically intact survival to discharge (odds ratio, 1.79; 95% CI, 1.09-2.94). Targeted temperature management 33°C was not associated with significantly improved hospital mortality. Targeted temperature management was implemented faster (1.9 vs 3.5 hr from 911 call; p < 0.001) and more frequently in the emergency department during the targeted temperature management 33°C period (87% vs 55%; p < 0.001). CONCLUSIONS: Comatose, adult out-of-hospital cardiac arrest patients treated during the targeted temperature management 33°C period had higher odds of neurologically intact survival to hospital discharge compared with those treated during the targeted temperature management 36°C period. There was no significant difference in hospital mortality.

Occupational exposures and programmatic response to COVID-19 pandemic: an emergency medical services experience.

Rigorous assessment of occupational COVID-19 risk and personal protective equipment (PPE) use is not well-described. We evaluated 9-1-1 emergency medical services (EMS) encounters for patients with COVID-19 to assess occupational exposure, programmatic strategies to reduce exposure and PPE use. We conducted a retrospective cohort investigation of laboratory-confirmed patients with COVID-19 in King County, Washington, USA, who received 9-1-1 EMS responses from 14 February 2020 to 26 March 2020. We reviewed dispatch, EMS and public health surveillance records to evaluate the temporal relationship between exposure and programmatic changes to EMS operations designed to identify high-risk patients, protect the workforce and conserve PPE. There were 274 EMS encounters for 220 unique COVID-19 patients involving 700 unique EMS providers with 988 EMS person-encounters. Use of 'full' PPE including mask (surgical or N95), eye protection, gown and gloves (MEGG) was 67%. There were 151 person-exposures among 129 individuals, who required 981 quarantine days. Of the 700 EMS providers, 3 (0.4%) tested positive within 14 days of encounter, though these positive tests were not attributed to occupational exposure from inadequate PPE. Programmatic changes were associated with a temporal reduction in exposures. When stratified at the study encounters midpoint, 94% (142/151) of exposures occurred during the first 137 EMS encounters compared with 6% (9/151) during the second 137 EMS encounters (p<0.01). By the investigation's final week, EMS deployed MEGG PPE in 34% (3579/10 468) of all EMS person-encounters. Less than 0.5% of EMS providers experienced COVID-19 illness within 14 days of occupational encounter. Programmatic strategies were associated with a reduction in exposures, while achieving a measured use of PPE.

Role of Health Information Technology in Addressing Health Disparities: Patient, Clinician, and System Perspectives.

Over the last decade, health information technology (IT) has dramatically transformed medical practice in the United States. On May 11-12, 2017, the National Institute on Minority Health and Health Disparities, in partnership with the National Science Foundation and the National Health IT Collaborative for the Underserved, convened a scientific workshop, "Addressing Health Disparities with Health Information Technology," with the goal of ensuring that future research guides potential health IT initiatives to address the needs of health disparities populations. The workshop examined patient, clinician, and system perspectives on the potential role of health IT in addressing health disparities. Attendees were asked to identify and discuss various health IT challenges that confront underserved communities and propose innovative strategies to address them, and to involve these communities in this process. Community engagement, cultural competency, and patient-centered care were highlighted as key to improving health equity, as well as to promoting scalable, sustainable, and effective health IT interventions. Participants noted the need for more research on how health IT can be used to evaluate and address the social determinants of health. Expanding public-private partnerships was emphasized, as was the importance of clinicians and IT developers partnering and using novel methods to learn how to improve health care decision-making. Finally, to advance health IT and promote health equity, it will be necessary to record and capture health disparity data using standardized terminology, and to continuously identify system-level deficiencies and biases.

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.

2017 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Summary.

The International Liaison Committee on Resuscitation has initiated a near-continuous review of cardiopulmonary resuscitation science that replaces the previous 5-year cyclic batch-and-queue approach process. This is the first of an annual series of International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations summary articles that will include the cardiopulmonary resuscitation science reviewed by the International Liaison Committee on Resuscitation in the previous year. The review this year includes 5 basic life support and 1 pediatric Consensuses on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Each of these includes a summary of the science and its quality based on Grading of Recommendations, Assessment, Development, and Evaluation criteria and treatment recommendations. Insights into the deliberations of the International Liaison Committee on Resuscitation task force members are provided in Values and Preferences sections. Finally, the task force members have prioritized and listed the top 3 knowledge gaps for each population, intervention, comparator, and outcome question.

Syringe Administration of Epinephrine by Emergency Medical Technicians for Anaphylaxis.

OBJECTIVE: In recent years, the costs of epinephrine autoinjectors (EAIs) in the United States have risen substantially. King County Emergency Medical Services implemented the "Check and Inject" program to replace EAIs by teaching emergency medical technicians (EMTs) to manually aspirate epinephrine from a single-use 1 mg/mL epinephrine vial using a needle and syringe followed by prehospital intramuscular administration of the correct adult or pediatric dose of epinephrine for anaphylaxis or serious allergic reaction. Treatment was guided by an EMT protocol that required a trigger and symptoms. We sought to determine if the "Check and Inject" program was safely implemented by EMTs treating presumed prehospital anaphylaxis or serious allergic reaction. METHODS: We conducted a prospective investigation of all cases treated as part of the "Check and Inject" program from July 2014 through December 2016 in suburban King County, Washington, and January 2016 through December 2016 within the city of Seattle. All cases were prospectively collected using a custom quality improvement data form completed by the first responding EMTs. Two physicians completed a structured review of each EMS medical record to determine if the EMTs followed the Check and Inject protocol and determine if epinephrine was clinically-indicated based on physician review. RESULTS: Of the 411 cases eligible for analysis, EMTs followed the protocol appropriately in 367 (89.3%) cases. In the remaining 44 (10.7%) cases, the EMS incident report form failed to document either a clear inciting allergic trigger or an appropriate symptom from the protocol list. Physician review determined that epinephrine was clinically indicated in 36 of the 44 cases. Among the remaining 8 cases (1.9%) that did not meet protocol criteria and were not clinically-indicated based on physician review, none had a documented adverse reaction to the epinephrine. CONCLUSION: We observed that EMTs successfully implemented the manual "Check and Inject" program for severe allergic reactions and anaphylaxis in a manner that typically agreed with physician review and without any overt identified safety issues.

Part 3: Adult Basic Life Support and Automated External Defibrillation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.

This review comprises the most extensive literature search and evidence evaluation to date on the most important international BLS interventions, diagnostics, and prognostic factors for cardiac arrest victims. It reemphasizes that the critical lifesaving steps of BLS are (1) prevention, (2) immediate recognition and activation of the emergency response system, (3) early high-quality CPR, and (4) rapid defibrillation for shockable rhythms. Highlights in prevention indicate the rational and judicious deployment of search-and-rescue operations in drowning victims and the importance of education on opioid-associated emergencies. Other 2015 highlights in recognition and activation include the critical role of dispatcher recognition and dispatch-assisted chest compressions, which has been demonstrated in multiple international jurisdictions with consistent improvements in cardiac arrest survival. Similar to the 2010 ILCOR BLS treatment recommendations, the importance of high quality was reemphasized across all measures of CPR quality: rate, depth, recoil, and minimal chest compression pauses, with a universal understanding that we all should be providing chest compressions to all victims of cardiac arrest. This review continued to focus on the interface of BLS sequencing and ensuring high-quality CPR with other important BLS interventions, such as ventilation and defibrillation. In addition, this consensus statement highlights the importance of EMS systems, which employ bundles of care focusing on providing high-quality chest compressions while extricating the patient from the scene to the next level of care. Highlights in defibrillation indicate the global importance of increasing the number of sites with public-access defibrillation programs. Whereas the 2010 ILCOR Consensus on Science provided important direction for the "what" in resuscitation (ie, what to do), the 2015 consensus has begun with the GRADE methodology to provide direction for the quality of resuscitation. We hope that resuscitation councils and other stakeholders will be able to translate this body of knowledge of international consensus statements to build their own effective resuscitation guidelines.

Part 2: Evidence Evaluation and Management of Conflicts of Interest: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.

The process for evaluating the resuscitation science has evolved considerably over the past 2 decades. The current process, which incorporates the use of the GRADE methodology, culminated in the 2015 CoSTR publication, which in turn will inform the international resuscitation councils' guideline development processes. Over the next few years, the process will continue to evolve as ILCOR moves toward a more continuous evaluation of the resuscitation science.