The relationship between shocks and survival in out-of-hospital cardiac arrest patients initially found in PEA or asystole.

OBJECTIVE: To describe survival rates from out-of-hospital cardiac arrest for patients who present with pulseless electrical activity or asystole according to whether they remained in a non-shockable rhythm or converted to ventricular fibrillation and were shocked appropriately. RESULTS: Observational analysis of a cardiac arrest registry collected as part of a randomized trial. SETTING: Five urban/suburban cities in the United States and Canada. PARTICIPANTS: Trial subjects (adult, treated, non-traumatic) whose first documented heart rhythm/state following cardiac arrest was asystole or pulseless electrical activity. INTERVENTION: Periodic pauses to assess for shockable rhythm. MAIN OUTCOME MEASURE: Survival to hospital discharge. RESULTS: Of 1377 cardiac arrest patients, 738 presented with an initial arrest rhythm/state of either pulseless electrical activity or asystole. Of the 738, 78% (n=574) subsequently remained in a non-shockable rhythm/state at each evaluation throughout the resuscitation (No-Shock group) while 22% (n=164) converted to ventricular fibrillation and were shocked by emergency medical service (Shock group). Survival to hospital discharge was significantly greater in the No-Shock group (4.9% versus 0.6%, p=0.01). Shock group remained a predictor (odds ratios=0.18, p=0.036) of death after adjustment for potential confounders. CONCLUSIONS: These results suggest that patients with cardiac arrest who develop VF during the course of treatment for initially observed pulseless electrical activity or asystole do not benefit from conventional approaches to treatment such as defibrillation. Further study is warranted to define the optimal treatment of this patient cohort.

Manual chest compression vs use of an automated chest compression device during resuscitation following out-of-hospital cardiac arrest: a randomized trial.

CONTEXT: High-quality cardiopulmonary resuscitation (CPR) may improve both cardiac and brain resuscitation following cardiac arrest. Compared with manual chest compression, an automated load-distributing band (LDB) chest compression device produces greater blood flow to vital organs and may improve resuscitation outcomes. OBJECTIVE: To compare resuscitation outcomes following out-of-hospital cardiac arrest when an automated LDB-CPR device was added to standard emergency medical services (EMS) care with manual CPR. DESIGN, SETTING, AND PATIENTS: Multicenter, randomized trial of patients experiencing out-of-hospital cardiac arrest in the United States and Canada. The a priori primary population was patients with cardiac arrest that was presumed to be of cardiac origin and that had occurred prior to the arrival of EMS personnel. Initial study enrollment varied by site, ranging from late July to mid November 2004; all sites halted study enrollment on March 31, 2005. INTERVENTION: Standard EMS care for cardiac arrest with an LDB-CPR device (n = 554) or manual CPR (n = 517). MAIN OUTCOME MEASURES: The primary end point was survival to 4 hours after the 911 call. Secondary end points were survival to hospital discharge and neurological status among survivors. RESULTS: Following the first planned interim monitoring conducted by an independent data and safety monitoring board, study enrollment was terminated. No difference existed in the primary end point of survival to 4 hours between the manual CPR group and the LDB-CPR group overall (N = 1071; 29.5% vs 28.5%; P = .74) or among the primary study population (n = 767; 24.7% vs 26.4%, respectively; P = .62). However, among the primary population, survival to hospital discharge was 9.9% in the manual CPR group and 5.8% in the LDB-CPR group (P = .06, adjusted for covariates and clustering). A cerebral performance category of 1 or 2 at hospital discharge was recorded in 7.5% of patients in the manual CPR group and in 3.1% of the LDB-CPR group (P = .006). CONCLUSIONS: Use of an automated LDB-CPR device as implemented in this study was associated with worse neurological outcomes and a trend toward worse survival than manual CPR. Device design or implementation strategies require further evaluation. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00120965.

Influenza immunizations provided by EMS agencies: the MEDICVAX Project.

OBJECTIVE: Emergency medical services (EMS) agencies may be an underutilized resource for provision of preventive health services. This study sought to demonstrate the feasibility for EMS agencies to provide influenza immunizations. METHODS: This prospective, observational cohort study was conducted with urban, suburban, and rural EMS agencies that volunteered to participate. EMS managers and paramedics attended an orientation program, and then developed and implemented recruitment strategies. Adult volunteer subjects who met Centers for Disease Control and Prevention criteria for influenza vaccination were enrolled. Paramedics obtained informed consent, determined subject eligibility, administered the vaccine, and observed each subject for 10 minutes. Paramedics, EMS managers, and subjects completed surveys; EMS managers reported costs and resource utilization. Data were analyzed descriptively. RESULTS: Ninety paramedics from 15 EMS agencies in three counties participated. Subjects were recruited by print and broadcast media and enrolled at 73 events held at retail establishments, community events, EMS stations, churches, senior citizen complexes, and private residences. Of the 2,075 adults immunized, 1,014 (49%) did not receive influenza vaccination in the previous year. Seven hundred five (34%) reported that they probably would not have been vaccinated elsewhere. Fixed cost for each immunization was $3.42. The EMS managers estimated their variable costs to range from zero dollars (volunteer agencies with all donated expenses) to $15.31 per immunization. No adverse events were reported. Subjects, paramedics, and EMS managers indicated a high level of satisfaction with the project. CONCLUSION: The MEDICVAX Project demonstrated the feasibility of EMS agencies to safely provide influenza immunizations. The project reached some adults who likely would not have been immunized.