Community Interventions for Out-of-Hospital Cardiac Arrest in Resource-Limited Settings: A Scoping Review Across Low, Middle, and High-Income Countries.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) is a major global health challenge, characterized by poor survival outcomes worldwide. Resource-limited settings are burdened with suboptimal emergency response and worse outcomes than high-resource areas. Engaging the community in the response to OHCA has the potential to improve outcomes, although an overview of community interventions in resource-limited settings has not been provided. OBJECTIVE: This review evaluated the scope of community-based OHCA interventions in resource-limited settings. METHODS: Literature searches in electronic databases (MEDLINE, EMBASE, Global Health, CINAHL, Cochrane Central Register of Controlled Clinical Trials) and grey literature sources were performed. Abstract screening, full-text review, and data extraction of eligible studies were conducted independently by two reviewers. The PCC (Population, Concept, and Context) framework was used to assess study eligibility. Studies that evaluated community-based interventions for laypeople (Population), targeting emergency response activation, cardiopulmonary resuscitation (CPR), or automated external defibrillator (AED) use (Concept) in resource-limited settings (Context) were included. Resource-limited settings were identified by financial pressures (low-income or lower-middle-income country, according to World Bank data on year of publication) or geographical factors (setting described using keywords indicative of geographical remoteness in upper-middle-income or high-income country). RESULTS: Among 14,810 records identified from literature searches, 60 studies from 28 unique countries were included in this review. Studies were conducted in high-income (n = 35), upper-middle-income (n = 2), lower-middle-income (n = 22), and low-income countries (n = 1). Community interventions included bystander CPR and/or AED training (n = 34), community responder programs (n = 8), drone-delivered AED networks (n = 6), dispatcher-assisted CPR programs (n = 4), regional resuscitation campaigns (n = 3), public access defibrillation programs (n = 3), and crowdsourcing technologies (n = 2). CPR and/or AED training were the only interventions evaluated in low-income, lower-middle-income, and upper-middle-income countries. CONCLUSIONS: Interventions aimed at improving the community response to OHCA in resource-limited settings differ globally. There is a lack of reported studies from low-income countries and certain continental regions, including South America, Africa, and Oceania. Evaluation of interventions other than CPR and/or AED training in low- and middle-income countries is needed to guide community emergency planning and health policies.

Sudden Cardiac Arrest during Participation in Competitive Sports.

BACKGROUND: The incidence of sudden cardiac arrest during participation in sports activities remains unknown. Preparticipation screening programs aimed at preventing sudden cardiac arrest during sports activities are thought to be able to identify at-risk athletes; however, the efficacy of these programs remains controversial. We sought to identify all sudden cardiac arrests that occurred during participation in sports activities within a specific region of Canada and to determine their causes. METHODS: In this retrospective study, we used the Rescu Epistry cardiac arrest database (which contains records of every cardiac arrest attended by paramedics in the network region) to identify all out-of-hospital cardiac arrests that occurred from 2009 through 2014 in persons 12 to 45 years of age during participation in a sport. Cases were adjudicated as sudden cardiac arrest (i.e., having a cardiac cause) or as an event resulting from a noncardiac cause, on the basis of records from multiple sources, including ambulance call reports, autopsy reports, in-hospital data, and records of direct interviews with patients or family members. RESULTS: Over the course of 18.5 million person-years of observation, 74 sudden cardiac arrests occurred during participation in a sport; of these, 16 occurred during competitive sports and 58 occurred during noncompetitive sports. The incidence of sudden cardiac arrest during competitive sports was 0.76 cases per 100,000 athlete-years, with 43.8% of the athletes surviving until they were discharged from the hospital. Among the competitive athletes, two deaths were attributed to hypertrophic cardiomyopathy and none to arrhythmogenic right ventricular cardiomyopathy. Three cases of sudden cardiac arrest that occurred during participation in competitive sports were determined to have been potentially identifiable if the athletes had undergone preparticipation screening. CONCLUSIONS: In our study involving persons who had out-of-hospital cardiac arrest, the incidence of sudden cardiac arrest during participation in competitive sports was 0.76 cases per 100,000 athlete-years. The occurrence of sudden cardiac arrest due to structural heart disease was uncommon during participation in competitive sports. (Funded by the National Heart, Lung, and Blood Institute and others.).

ICD Implantation Rates in Cardiac Arrest Survivors in Canada.

Background: Patients resuscitated from out-of-hospital cardiac arrest (OHCA) are at high risk of recurrence, posing a substantial burden on healthcare systems. Despite the established benefit of implantable cardioverter defibrillator (ICD) therapy in many such patients, and recommendations by guidelines, few studies have described the proportion of OHCA patients who receive guideline-concordant care. Methods: The Canadian Institute for Health Information Discharge Abstract Database dataset was used to identify OHCA patients admitted to hospitals across Canada, excluding Quebec. We analyzed all patients without a probable ischemic or bradycardia etiology of cardiac arrest, who survived to discharge, to estimate the ICD implantation rates in patients who were potentially eligible to have an ICD. Results: Between 2013 and 2017, a total of 10,435 OHCA patients who were admitted to the hospital were captured in the database; 4486 (43%) survived to hospital discharge, and 2580 survivors (57.5%) were potentially eligible to receive an ICD. Among these potentially eligible patients, 757 (29.3%) received an ICD during their index admission or within 30 days after discharge from the hospital. The ICD implantation rate during index admission increased from 13.8% in 2013 to 19.6% in 2017 (P-value for time trend < 0.05). The rate of ICD implantations in potentially eligible patients was higher in urban than in rural settings (19.5% vs 11.1%) and in teaching vs community hospitals (34.7% vs 9.8%). Conclusions: Although ICD implantation rates show an increasing trend among patients with OHCA who are likely eligible for secondary prevention, significant underutilization of ICDs persists in these patients.

Contexte: Les patients ayant survécu à un arrêt cardiaque extra-hospitalier (ACEH) présentent un risque élevé de récidive, ce qui impose un lourd fardeau aux systèmes de soins de santé. Malgré l'avantage établi de la mise en place d'un défibrillateur cardioverteur implantable (DCI) chez un grand nombre de ces patients, et les recommandations des lignes directrices, peu d'études décrivent la proportion de patients victimes d'un ACEH ayant reçu des soins conformes aux lignes directrices. Méthodologie: Nous avons recensé les admissions à l'hôpital de patients ayant subi un ACEH au Canada, à l'exception du Québec à partir de l'ensemble de données de la Base de données sur les congés des patients de l'Institut canadien d'information sur la santé. Nous avons inclus dans notre analyse tous les patients pour lesquels la cause de l'arrêt cardiaque n'était probablement pas ischémique ou bradycardique et qui avaient survécu jusqu'à leur congé de l'hôpital, afin d'estimer les taux d'implantation d'un DCI chez les patients potentiellement admissibles à cette intervention. Résultats: Entre 2013 et 2017, un total de 10 435 patients ayant subi un ACEH ont été hospitalisés selon la base de données; 4 486 (43 %) avaient survécu jusqu'à leur congé de l'hôpital, et 2 580 survivants (57,5 %) étaient potentiellement admissibles à l'implantation d'un DCI. Parmi les patients potentiellement admissibles, 757 (29,3 %) avaient reçu un DCI au moment de leur admission initiale ou dans les 30 jours suivant leur congé de l'hôpital. Le taux d'implantation de DCI lors de l'admission initiale est passé de 13,8 % en 2013 à 19,6 % en 2017 (valeur p pour la tendance au fil du temps < 0,05). Le taux d'implantation d'un DCI chez les patients potentiellement admissibles était plus élevé en milieu urbain qu'en milieu rural (19,5 % contre 11,1 %) et dans les hôpitaux d'enseignement/universitaires par comparaison avec les hôpitaux communautaires (34,7 % contre 9,8 %). Conclusions: Bien que les taux d'implantation de DCI affichent une tendance à la hausse chez les patients ayant subi un ACEH qui sont probablement admissibles à des interventions de prévention secondaire, les DCI demeurent largement sous-utilisés chez ces patients.

Mediators of the Association Between Socioeconomic Status and Survival After Out-of-Hospital Cardiac Arrest: A Systematic Review.

Low socioeconomic status (SES) is associated with poor outcomes after out-of-hospital cardiac arrest (OHCA). Patient characteristics, care processes, and other contextual factors may mediate the association between SES and survival after OHCA. Interventions that target these mediating factors may reduce disparities in OHCA outcomes across the socioeconomic spectrum. This systematic review identified and quantified mediators of the SES-survival after OHCA association. Electronic databases (MEDLINE, Embase, PubMed, Web of Science) and grey literature sources were searched from inception to July or August 2023. Observational studies of OHCA patients that conducted mediation analyses to evaluate potential mediators of the association between SES (defined by income, education, occupation, or a composite index) and survival outcomes were included. A total of 10 studies were included in this review. Income (n = 9), education (n = 4), occupation (n = 1), and composite indices (n = 1) were used to define SES. The proportion of OHCA cases that had bystander involvement, presented with an initial shockable rhythm, and survived to hospital discharge or 30 days increased with higher SES. Common mediators of the SES-survival association that were evaluated included initial rhythm (n = 6), emergency medical services response time (n = 5), and bystander cardiopulmonary resuscitation (n = 4). Initial rhythm was the most important mediator of this association, with a median percent excess risk explained of 37.4% (range 28.6%-40.0%; n = 5; 1 study reported no mediation) and mediation proportion of 41.8% (n = 1). To mitigate socioeconomic disparities in outcomes after OHCA, interventions should target potentially modifiable mediators, such as initial rhythm, which may involve improving bystander awareness of OHCA and the need for prompt resuscitation.

Methods to teach schoolchildren how to perform and retain cardiopulmonary resuscitation (CPR) skills: A systematic review and meta-analysis.

Background: Worldwide, bystander CPR rates are low; one effective way to increase these rates is to train schoolchildren; however, the most effective way to train them is currently unknown. Methods: This systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies, evaluated whether CPR training for schoolchildren, using innovative teaching modalities (nonpractical, self, or peer-training) versus standard instructor-led training, resulted in higher quality CPR, self-confidence and short-term (≤3 months post-training) or long-term (>3 months post-training) retention of CPR skills. Results: From 9793 citations, 96 studies published between 1975 and 2022 (44 RCTs and 52 before/after studies) were included. There were 43,754 students, average age of 11.5 ±â€¯0.9 (range 5.9-17.6) and 49.2% male. Only 13 RCTs compared practical vs. nonpractical training (n = 5), self- vs. instructor-led training (n = 7) or peer- vs. instructor-led training (n = 5). The observed statistically significant differences in mean depth and rate of compressions between children with hands-on practical training and those without were not clinically relevant. Regardless of training modality, compression depth was consistently suboptimal. No differences were observed in CPR skills immediately or ≤ 3 months post-training, between children who were self- or peer-trained vs. instructor-led. Due to lack of data, we were unable to evaluate the impact of these novel training modalities on student self-confidence. Conclusion: Although innovative training modalities are equally effective to instructor-led training when teaching schoolchildren CPR, compression depth was frequently suboptimal. Recommendations on standardized training and evaluation methods are necessary to understand the best ways to train children.

"It's Overwhelming With the Grief" A Qualitative Study of Families' Experiences When a Young Relative Dies of Sudden Cardiac Death.

BACKGROUND: Sudden cardiac death (SCD) in younger individuals is frequently caused by heritable cardiac conditions. The unexpected nature of SCD leaves families with many unanswered questions and an insufficient understanding of the cause of death and their own risk for heritable disease. We explored the experiences of families of young SCD victims upon learning about their relative's cause of death and how they perceive their own risk for heritable cardiac conditions. METHODS: We conducted a qualitative descriptive study, by interviewing families of young (ages 12-45) SCD victims, who died between 2014 and 2018 from a heritable cardiac condition and were investigated by the Office of the Chief Coroner of Ontario, Canada. We used thematic analysis to analyze the transcripts. RESULTS: Between 2018 and 2020, we interviewed 19 family members, of which 10 were males and 9 were females, ages ranging from 21 to 65 (average 46.2±13.1). Four main themes were revealed, each representing a distinct time period that families experience along a trajectory: (1) interactions between bereaved family and others, in particular coroners, shaped their search for answers about their relative's cause of death, with the types, formats, and timing of communication varying by case; (2) searching for answers and processing the cause of death; (3) incidental implications of the SCD event, such as financial strain and lifestyle changes contributed to cumulative stress; (4) receiving answers (or not) and moving forward. CONCLUSIONS: Families rely on communication with others, yet the type, formats, and timing of information received varies, which can influence families' experiences of processing the death (and its cause), their perceived risk and their decision to pursue cascade screening. These results may provide key insights for the interprofessional health care team responsible for the delivery and communication of the cause of death to families of SCD victims.

Shared Decision-Making in Athletes Diagnosed With a Cardiovascular Condition: A Scoping Review.

This scoping review summarizes existing approaches, benefits, and barriers to shared decision-making (SDM) in the context of sports cardiology. Among 6,058 records screened, 37 articles were included in this review. Most included articles defined SDM as an open dialogue between the athlete, healthcare team, and other stakeholders. The benefits and risks of management strategies, treatment options, and return-to-play were the focus of this dialogue. Key components of SDM were described through various themes, such as emphasizing patient values, considering nonphysical factors, and informed consent. Benefits of SDM included enhancing patient understanding, implementing a personalized management plan, and considering a holistic approach to care. Barriers to SDM included pressure from institutions, consideration of multiple perspectives in decision-making, and the potential liability of healthcare providers. The use of SDM when discussing management, treatment, and lifestyle modification for athletes diagnosed with a cardiovascular condition is necessary to ensure patient autonomy and engagement.

Perceived self-efficacy and empowerment in patients at increased risk of sudden cardiac arrest.

Background: The role of multidisciplinary clinics for psychosocial care is increasingly recognized for those living with inherited cardiac conditions (ICC). In Canada, access to healthcare providers differ between clinics. Little is known about the relationship between access to specialty care and a patient's ability to cope with, and manage their condition. Methods: We leveraged the Hearts in Rhythm Organization (HiRO) to conduct a cross-sectional, community-based survey of individuals with ICC and their family members. We aimed to describe access to services, and explore the relationships between participants' characteristics, cardiac history and self-reported health status and self-efficacy (GSE: General Self-Efficacy Scale) and empowerment (GCOS-24: Genetic Counseling Outcome Scale). Results: We collected 235 responses from Canadian participants in 10 provinces and territories. Overall, 63% of participants reported involvement of a genetic counsellor in their care. Access to genetic testing was associated with greater empowerment [mean GCOS-24: 121.14 (SD = 20.53) vs. 105.68 (SD = 21.69); p = 0.004]. Uncertain genetic test results were associated with lower perceived self-efficacy (mean GSE: uncertain = 28.85 vs. positive = 33.16, negative = 34.13; p = 0.01). Low global mental health scores correlated with both lower perceived self-efficacy and empowerment scores, with only 11% of affected participants reporting involvement of psychology services in their care. Conclusion: Differences in resource accessibility, clinical history and self-reported health status impact the perceived self-efficacy and empowerment of patients with ICC. Future research evaluating interventions to improve patient outcomes is recommended.

Understanding Etiologies of Cardiac Arrest: Seeking Definitional Clarity.

Cardiac arrest leading to death and sudden cardiac death (SCD) may refer implicitly to situations in which death is unexpected and primarily of cardiac cause. National and international societies have published differing definitions for the various terms relating to cardiac arrest and SCD. We highlight the controversies in defining SCD, including the lack of a universal definition, the heterogeneity in the operationalization of the term "sudden," and limitations of time-based systems of SCD classification. We discuss the importance of a standardized methodology for classifying cardiac arrest as recommended by the World Health Organization (WHO) that should include use of multisource evidence (eg, coroner, autopsy, and toxicology reports) for confirming or refuting a cardiac cause of arrest. We reveal how a universal definition of SCD has been incorrectly attributed to the WHO and how this has been perpetuated in the literature. We make the case that definitional clarity is essential to understanding epidemiology, evaluating novel treatments, forming international collaboration, and innovating public health prevention strategies. We propose a practical schema to categorize cardiac arrest events to describe and study this population more accurately.

Responding to Cardiac Arrest in the Community in the Digital Age.

Sudden cardiac arrest (SCA) is a common event, affecting almost 400,000 individuals annually in North America. Initiation of cardiopulmonary resuscitation (CPR) and early defibrillation using an automated external defibrillator (AED) are critical for survival, yet many bystanders are reluctant to intervene. Digital technologies, including mobile devices, social media, and crowdsourcing might help play a role to improve survival from SCA. In this article we review the current digital tools and strategies available to increase rates of bystander recognition of SCA, prompt immediate activation of emergency medical services (EMS), initiate high-quality CPR, and to locate, retrieve, and operate AEDs. Smartphones can help to educate and connect bystanders with EMS dispatchers, through text messaging or video calling, to encourage the initiation of CPR and retrieval of the closest AED. Wearable devices and household smart speakers could play a future role in continuous vital signs monitoring in individuals at risk of lethal arrhythmias and send an alert to either chosen contacts or EMS. Machine learning algorithms and mathematical modelling might aid EMS dispatchers with better recognition of SCA as well as policymakers with where to best place AEDs for optimal accessibility. There are challenges with the use of digital tech, including the need for government regulation and issues with data ownership, accessibility, and interoperability. Future research will include smart cities, e-linkages, new technologies, and using social media for mass education. Together or in combination, these emerging digital technologies might represent the next leap forward in SCA survival.

Urban-Rural Differences in Cardiac Arrest Outcomes: A Retrospective Population-Based Cohort Study.

Background: Approximately 10% of people who suffer an out-of-hospital cardiac arrest (OHCA) treated by paramedics survive to hospital discharge. Survival differs by up to 19.2% between urban centres and rural areas. Our goal was to investigate the differences in OHCA survival between urban centres and rural areas. Methods: This was a retrospective cohort study of OHCA patients treated by Nova Scotia Emergency Medical Services (EMS) in 2017. Cases of traumatic, expected, and noncardiac OHCA were excluded. Data were collected from the Emergency Health Service electronic patient care record system and the discharge abstract database. Geographic information system analysis classified cases as being in urban centres (population > 1000 people) or rural areas, using 2016 Canadian Census boundaries. The primary outcome was survival to hospital discharge. Multivariable logistic regression covariates were age, sex, bystander resuscitation, whether the arrest was witnessed, public location, and preceding symptoms. Results: A total of 510 OHCAs treated by Nova Scotia Emergency Medical Services were included for analysis. A total of 12% (n = 62) survived to discharge. Patients with OHCAs in urban centres were 107% more likely to survive than those with OHCAs in rural areas (adjusted odds ratio = 2.1; 95% confidence interval = 1.1 to 3.8; P = 0.028). OHCAs in urban centres had a significantly shorter mean time to defibrillation of shockable rhythm (11.2 minutes ± 6.2) vs those in rural areas (17.5 minutes ± 17.3). Conclusions: Nova Scotia has an urban vs rural disparity in OHCA care that is also seen in densely populated OHCA centres. Survival is improved in urban centres. Further improvements in overall survival, especially in rural areas, may arise from community engagement in OHCA recognition and optimized healthcare delivery.

Contexte: Environ 10 % des personnes qui subissent un arrêt cardiaque en milieu extrahospitalier (ACEH), traité par des intervenants paramédicaux, survivent jusqu'à leur congé de l'hôpital. Le taux de survie peut différer de 19,2 % entre les centres urbains et les régions rurales. Notre étude visait à étudier les différences en matière de survie après un ACEH entre les centres urbains et les régions rurales. Méthodologie: Il s'agissait d'une étude de cohorte rétrospective portant sur des patients ayant subi un ACEH traité par les services médicaux d'urgence de la Nouvelle-Écosse en 2017. Les cas d'ACEH traumatique, prévu et non cardiaque ont été exclus. Les données ont été recueillies à partir du système de dossiers électroniques de soins aux patients des services médicaux d'urgence et de la Base de données sur les congés des patients. L'analyse du système d'information géographique a classé les cas selon qu'ils sont survenus dans un centre urbain (population de plus de 1 000 personnes) ou dans une région rurale, en utilisant les limites du recensement canadien de 2016. Le principal paramètre d'évaluation était la survie à la sortie de l'hôpital. Les covariables utilisées dans la régression logistique multivariée étaient l'âge, le sexe, la réanimation effectuée par des témoins si présents lors de l'arrêt cardiaque, l'emplacement public et les symptômes précédents. Résultats: Au total, 510 ACEH traités par les services médicaux d'urgence de la Nouvelle-Écosse ont été inclus aux fins de l'analyse. En tout, 12 % (n = 62) des sujets ont survécu jusqu'à leur congé hospitalier. Les patients ayant subi un ACEH dans un centre urbain étaient 107 % plus susceptibles de survivre que ceux ayant subi un ACEH dans une région rurale (rapport de cotes ajusté : 2,1; intervalle de confiance à 95 % : 1,1 ­ 3,8; p = 0,028). Le temps moyen de délivrance d'un choc lors d'un ACEH avec rythme défibrillable est significativement plus court (11,2 ± 6,2 minutes) dans un centre urbain que dans une région rurale (17,5 ± 17,3 minutes). Conclusions: La Nouvelle-Écosse fait état d'une disparité dans les soins de l'ACEH entre les régions urbaines et les régions rurales, que l'on observe également dans les villes densément peuplées. La survie est plus longue dans les centres urbains. Il est possible de prolonger davantage la survie globale, en particulier dans les régions rurales, en sensibilisant la communauté à l'ACEH et en optimisant la prestation des soins de santé.

Association between sex and survival after non-traumatic out of hospital cardiac arrest: A systematic review and meta-analysis.

BACKGROUND: Existing studies have shown conflicting results regarding the relationship of sex with survival after out of hospital cardiac arrest (OHCA). This systematic review evaluates the association of female sex with survival to discharge and survival to 30 days after non-traumatic OHCA. METHODS: We searched Medline, Embase, CINAHL, Web of Science, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews from inception through June 2021 for studies evaluating female sex as a predictor of survival in adult patients with non-traumatic cardiac arrest. Random-effects inverse variance meta-analyses were performed to calculate pooled odds ratios (ORs) with 95% confidence intervals (CI). The GRADE approach was used to assess evidence quality. RESULTS: Thirty studies including 1,068,788 patients had female proportion of 41%. There was no association for female sex with survival to discharge (OR 1.03, 95% CI 0.95-1.12; I2 = 89%). Subgroup analysis of low risk of bias studies demonstrated increased survival to discharge for female sex (OR 1.20, 95% CI 1.18-1.23; I2 = 0%) and with high certainty, the absolute increase in survival was 2.2% (95% CI 0.1-3.6%). Female sex was not associated with survival to 30 days post-OHCA (OR 1.02, 95% CI 0.92-1.14; I2 = 79%). CONCLUSIONS: In adult patients experiencing OHCA, with high certainty in the evidence from studies with low risk of bias, female sex had a small absolute difference for the outcome survival to discharge and no difference in survival at 30 days. Future models that aim to stratify risk of survival post-OHCA should focus on sex-specific factors as opposed to sex as an isolated prognostic factor.

Mandating Training Is Not Enough: The State of Cardiopulmonary Resuscitation and Automated External Defibrillator Training in Ontario Schools.

Cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) training in schools are mandated in the Ontario high school curriculum. We surveyed schools to understand the scope of this training, including its barriers and facilitators. We recruited 120 (58.5%) elementary, 25 (12.2%) middle, and 60 (29.3%) high schools. Almost 60% (120 of 200) provided staff with CPR training, but only 56% (27 of 48) of high schools trained students. Major barriers included lack of funding, time, and trainers. Despite government-mandated curriculum, only 56% of high schools offer CPR and AED training. More research is needed to understand the barriers to implementing this lifesaving training.

La formation en réanimation cardiorespiratoire (RCR) et défibrillateurs externes automatisés (DEA) est obligatoire dans le cadre du programme d'études secondaires des écoles de l'Ontario. Nous avons entrepris une enquête dans les écoles pour comprendre la portée de cette formation, notamment ses obstacles et ses facilitateurs. Nous avons procédé au recrutement dans 120 (58,5 %) écoles élémentaires, 25 (12,2 %) écoles intermédiaires et 60 (29,3 %) écoles secondaires. Presque 60 % (120 sur 200) des écoles secondaires offraient la formation en RCR au personnel, mais seulement 56 % (27 sur 48) formaient les élèves. Les principaux obstacles étaient le manque de financement, de temps et de formateurs. Bien que le gouvernement ait rendu obligatoire la formation en RCR et DEA dans le cadre du programme d'études secondaires, seulement 56 % des écoles offrent la formation. D'autres études sont nécessaires pour comprendre les obstacles à la mise en œuvre de cette formation qui permet de sauver des vies.

Optimal in-hospital defibrillator placement.

AIMS: To determine if mathematical optimization of in-hospital defibrillator placements can reduce in-hospital cardiac arrest-to-defibrillator distance compared to existing defibrillators in a single hospital. METHODS: We identified treated IHCAs and defibrillator placements in St. Michael's Hospital in Toronto, Canada from Jan. 2013 to Jun. 2017 and mapped them to a 3-D computer model of the hospital. An optimization model identified an equal number of optimal defibrillator locations that minimized the average distance between IHCAs and the closest defibrillator using a 10-fold cross-validation approach. The optimized and existing defibrillator locations were compared in terms of average distance to the out-of-sample IHCAs. We repeated the analysis excluding intensive care units (ICUs), operating theatres (OTs), and the emergency department (ED). We also re-solved the model using fewer defibrillators to determine when the average distance matched the performance of existing defibrillators. RESULTS: We identified 433 treated IHCAs and 53 defibrillators. Of these, 167 IHCAs and 31 defibrillators were outside of ICUs, OTs, and the ED. Optimal defibrillator placements reduced the average IHCA-to-defibrillator distance from 16.1 m to 2.7 m (relative decrease of 83.0%; P = 0.002) compared to existing defibrillator placements. For non-ICU/OT/ED IHCAs, the average distance was reduced from 24.4 m to 11.9 m (relative decrease of 51.3%; P = 0.002. 8-9 optimized defibrillator locations were sufficient to match the average IHCA-to-defibrillator distance of existing defibrillator placements. CONCLUSIONS: Optimization-guided placement of in-hospital defibrillators can reduce the distance from an IHCA to the closest defibrillator. Equivalently, optimization can match existing defibrillator performance using far fewer defibrillators.

High risk neighbourhoods: The effect of neighbourhood level factors on cardiac arrest incidence.

BACKGROUND: Numerous studies have shown significant neighbourhood level variation in out-of-hospital cardiac arrest (OHCA) incidence rates, however, few have provided an explanation for these disparities beyond traditional socioeconomic measures. METHODS: This was a retrospective study using data from a large population-based OHCA database (Rescu Epistry). We included adults ≥20 years who experienced a non-traumatic OHCA and were treated by emergency medical services within Toronto, Canada between 2006-2012. The residential address of each OHCA patient was spatially mapped to 1 of 517 Toronto census tracts (CTs). Patient and CT level characteristics were included in multivariate regression models to assess their association with OHCA incidence per 100,000 persons. RESULTS: Of the 7775 OHCAs occurring in the study area, 7692 (98.9%) were eligible for inclusion. OHCA incidence rates varied widely across CT quintiles, with rates differing almost 4-fold (109.1 per 100,000 yearly Q5 most deprived vs. 30.0 per 100,000 yearly Q1 least deprived p < 0.0001). Numerous areas of high incidence adjacent to areas of low incidence were observed. After adjustment, all variables except the Activity Friendly Index showed highly significant linear trends, with increasing age, sex ratio, diabetes prevalence, material deprivation and ethnic concentration being independently associated with increasing OHCA incidence. In contrast, we did not observe a linear relationship between high OHCA incidence and median household income. CONCLUSIONS: This study showed almost 4-fold OHCA incidence variability across a large metropolitan area. This variability was partially correlated with population and health data, but not typical socioeconomic predictors, such as median household income.

Health-Related Quality of Life in Patients With Atrial Fibrillation Treated With Catheter Ablation or Antiarrhythmic Drug Therapy: A Systematic Review and Meta-analysis.

BACKGROUND: Catheter ablation (CA) is performed in patients with atrial fibrillation (AF) to reduce symptoms and improve health-related quality of life (HRQL). METHODS: This systematic review and meta-analysis of randomized controlled trials (RCTs) evaluated CA of any energy modality compared with antiarrhythmic drugs (AADs) using inverse-variance random-effects models. We searched for RCTs reporting HRQL and AF-related symptoms at 3, 6, 12, 24, 48, and 60 months after treatment as well as the number of repeat ablations. RESULTS: Of 15,878 records, we included 13 RCTs of CA vs AADs for the analyses of HRQL, 7 RCTs for the analyses of AF-related symptoms, and 13 RCTs for the number of repeat ablations. For the HRQL analyses at 3 months, there were significant increases in both the Physical Component Summary score (3 months' standardized mean difference = 0.58 [0.39-0.78]; P < 0.00001, I 2 = 6%, 3 trials, n = 443) and the Mental Component Summary score (3 months' standardized mean difference = 0.57 [0.37-0.77]; P < 0.00001, I 2 = 0%, 3 trials, n = 443), favouring CA over AADs. These differences were sustained at 12 months but not >24 months after randomization. Similar results were seen for AF-related symptoms. The number of repeat ablations and success rates after procedure varied considerably across trials. CONCLUSIONS: Evidence from few trials suggests that CA improves physical and mental health and AF-related symptoms in the short term, but these benefits decrease with time. More trials, reporting both HRQL and AF-related symptoms, at consistent time points are needed to assess the effectiveness of CA for the treatment of AF.

CONTEXTE: L'ablation par cathéter (AC) est réalisée chez les patients atteints de fibrillation auriculaire (FA) afin d'atténuer les symptômes et d'améliorer la qualité de vie liée à la santé (QVLS). MÉTHODOLOGIE: Cette revue systématique et méta-analyse d'essais contrôlés à répartition aléatoire (ECRA) a permis d'évaluer l'AC, toutes modalités énergétiques confondues, comparativement aux agents antiarythmiques (AA) à l'aide de modèles à effets aléatoires à variance inverse. Nous avons recherché les ECRA qui faisaient état de la QVLS et des symptômes liés à la FA à 3, 6, 12, 24, 48 et 60 mois après le traitement et qui précisaient le nombre d'ablations répétées. RÉSULTATS: À partir de 15 878 entrées, nous avons retenu 13 ECRA comparant l'AC à des AA pour l'analyse de la QVLS, 7 autres pour l'analyse des symptômes liés à la FA et 13 de plus aux fins de calcul du nombre d'ablations répétées. L'analyse de la QVLS à 3 mois indique une augmentation significative du score sommaire de la composante physique (différence moyenne normalisée à 3 mois = 0,58 [0,39-0,78]; p < 0,00001, I 2 = 6 %, 3 essais, n = 443) et du score sommaire de la composante mentale (différence moyenne normalisée à 3 mois = 0,57 [0,37-0,77]; p < 0,00001, I 2 = 0 %, 3 essais, n = 443), faisant pencher la balance en faveur de l'AC plutôt que des AA. Ces différences persistaient à 12 mois après la répartition aléatoire, mais pas aux moments d'évaluation ultérieurs (24, 48 et 60 mois). Des résultats similaires ont été observés au chapitre des symptômes liés à la FA. Le nombre d'ablations répétées et le taux de réussite postopératoire variaient considérablement d'un essai à l'autre. CONCLUSIONS: Les données probantes de quelques essais donnent à penser que l'AC améliore la santé physique et mentale ainsi que les symptômes liés à la FA à court terme, mais que ces bienfaits s'atténuent avec le temps. D'autres essais faisant état de la QVLS et des symptômes liés à la FA, à des moments d'évaluation constants, devront être réalisés pour évaluer l'efficacité réelle de l'AC dans le traitement de la FA.

First aid cooling techniques for heat stroke and exertional hyperthermia: A systematic review and meta-analysis.

BACKGROUND: Heat stroke is an emergent condition characterized by hyperthermia (>40 °C/>104 °F) and nervous system dysregulation. There are two primary etiologies: exertional which occurs during physical activity and non-exertional which occurs during extreme heat events without physical exertion. Left untreated, both may lead to significant morbidity, are considered a special circumstance for cardiac arrest, and cause of mortality. METHODS: We searched Medline, Embase, CINAHL and SPORTDiscus. We used Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods and risk of bias assessments to determine the certainty and quality of evidence. We included randomized controlled trials, non-randomized trials, cohort studies and case series of five or more patients that evaluated adults and children with non-exertional or exertional heat stroke or exertional hyperthermia, and any cooling technique applicable to first aid and prehospital settings. Outcomes included: cooling rate, mortality, neurological dysfunction, adverse effects and hospital length of stay. RESULTS: We included 63 studies, of which 37 were controlled studies, two were cohort studies and 24 were case series of heat stroke patients. Water immersion of adults with exertional hyperthermia [cold water (14-17 °C/57.2-62.6 °F), colder water (8-12 °C/48.2-53.6 °F) and ice water (1-5 °C/33.8-41 °F)] resulted in faster cooling rates when compared to passive cooling. No single water temperature range was found to be associated with a quicker core temperature reduction than another (cold, colder or ice). CONCLUSION: Water immersion techniques (using 1-17 °C water) more effectively lowered core body temperatures when compared with passive cooling, in hyperthermic adults. The available evidence suggests water immersion can rapidly reduce core body temperature in settings where it is feasible.

2020 International Consensus on First Aid Science With Treatment Recommendations.

This is the summary publication of the International Liaison Committee on Resuscitation's 2020 International Consensus on First Aid Science With Treatment Recommendations. It addresses the most recent published evidence reviewed by the First Aid Task Force science experts. This summary addresses the topics of first aid methods of glucose administration for hypoglycemia; techniques for cooling of exertional hyperthermia and heatstroke; recognition of acute stroke; the use of supplementary oxygen in acute stroke; early or first aid use of aspirin for chest pain; control of life- threatening bleeding through the use of tourniquets, haemostatic dressings, direct pressure, or pressure devices; the use of a compression wrap for closed extremity joint injuries; and temporary storage of an avulsed tooth. Additional summaries of scoping reviews are presented for the use of a recovery position, recognition of a concussion, and 6 other first aid topics. The First Aid Task Force has assessed, discussed, and debated the certainty of evidence on the basis of Grading of Recommendations, Assessment, Development, and Evaluation criteria and present their consensus treatment recommendations with evidence-to-decision highlights and identified priority knowledge gaps for future research. The 2020 International Consensus on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) Science With Treatment Recommendations (CoSTR) is the fourth in a series of annual summary publications from the International Liaison Committee on Resuscitation (ILCOR). This 2020 CoSTR for first aid includes new topics addressed by systematic reviews performed within the past 12 months. It also includes updates of the first aid treatment recommendations published from 2010 through 2019 that are based on additional evidence evaluations and updates. As a result, this 2020 CoSTR for first aid represents the most comprehensive update since 2010.

Validation of a universal prehospital termination of resuscitation clinical prediction rule for advanced and basic life support providers.

BACKGROUND: Prehospital termination of resuscitation rules have been derived for Emergency Medical Technician-Paramedics providing advanced life support care and defibrillation-only Emergency Medical Technicians providing basic life support care. We sought to externally validate each rule on a prospective cohort of prehospital cardiac arrest patients to determine if either rule could be proposed as a universal prehospital termination of resuscitation rule. METHODS: Investigators at the University of Toronto performed a secondary cohort analysis of data prospectively collected for the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest trial from 1 April 2006 to 1 April 2007 by one site. The diagnostic test characteristics and predicted transportation rate were calculated for each rule. RESULTS: Of the 2415 patients with cardiac arrest of presumed cardiac etiology, the advanced life support rule recommended termination of resuscitation for 743 patients. No survivors were identified in this group. It had a specificity of 100% for recommending transport of potential survivors, a positive predictive value of 100% for death and a predicted transport rate of 69%. The basic life support rule recommended termination of resuscitation for 1302 patients, with no survivors. This rule had a specificity of 100%, a positive predictive value of 100% and a predicted transport rate of 46%. CONCLUSIONS: Implementing the basic life support rule as a universal termination of resuscitation clinical prediction rule would result in a lower overall transport rate without missing any potential survivors. The universal rule would recommend termination of resuscitation when there was no return of spontaneous circulation prior to transport, no shock was given and the arrest was not witnessed by Emergency Medical Services personnel. This rule may be useful for emergency medical services systems with mixed levels of providers responding to cardiac arrest patients.