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Continuation of cardiopulmonary resuscitation in a Chinese hospital after unsuccessful EMS resuscitation

By Anthony Collins,2014-01-26 11:33
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Continuation of cardiopulmonary resuscitation in a Chinese hospital after unsuccessful EMS resuscitation

    Continuation of cardiopulmonary

    resuscitation in a Chinese hospital after

    unsuccessful EMS resuscitation

    142JournalofGeriatricCardiologySeptember2009Vol6No3

    CtinicalResearch

    ContinuationofcardiopulmonaryresuscitationinaChinese

    hospitalafterunsuccessfulEMSresuscitation

    XiaoBeYang,YanZhao,FeiWang

    ,.EmergencyDepartment,ZhongnanHospitalofWuhanUniversity,Wuhan430071,China 2.WuhanCenterforMedicalEmergency,Wuhan43000~China

    obiectiveToevaluatetheefficacyofthecontinuationofcardiopulmonaryresuscitafton(cPR)~llowingtransportationtothe

    emergencydepartmentinaChinesehospitalafterunsuccessfulemergencymedicalservices(EMS)CPR.MethodsFromJanuary2002

    toDecember2007,emergencyrecordsofnon

    traumaticpatientswhoweretransportedtoatertiaryteachinghospitalafterunsuccessful EMSCPRwerereviewed.ResultsEigty-fivepatientswereincluded,and13patients(15%)accomplishedrestorationofspontaneous

    circulationinouremergencydepartment.Resuscitativepossibilityreachedzeroataround23minutes.Onepatientwasdischargedwith

    afavourableneurologicoutcome.ConclusionsThisstudyshowsthatthecontinuationofCPRisnotfutileandmayimprove

    outcomes.Theoutcomesshouldbere

    evaluatedinthefuturewhenprehospitalinformationcanbecombinedwithin-hospitalinformation

    tJGeriatrCardiol2009;6:142146).

Keywordscardiacarrest;cardiopulmonaryresuscitation(CPR);emergencymedicalservice

    s(EMS);advancedcardiaclife

    support(ACLS)

    Introduction

    Out.of-hospitalcardiacarrests(OHCA)areatleast twiceasfrequentasinhospitalcardiacarrests.,When

    0HCAoccurs.emergencymedicalservices(EMS)should beinitiatedsothatprofessionalcardiopulmonaryresusci

    tationwillbeprovidedasearlyaspossible.However,retum tospontaneouscirculationoccursinonly16%35%ofDa-

    tientswithOHCA.Someoftheremainingpatientsare

    transportedtoin.hospitalemergencydepartmentswhere cardiopulmonaryresuscitation(CPR,iscontinued.Fewdata areavailableontheefficacyofprehospitalresuscitationor continuedCPRinChina.Wereviewedtheresuscitativepro

    cessandhospitalcourseofthepatientswhoweretrans. portedtotheemergencydepartmentofaChinesetertiary hospitalafterunsuccessfu1EMSCPR.

    Methods

    OurstudyprotocolwasapprovedbytheInstitutional ReviewBoardofZhongnanHospitalofWuhanUniversity andwritteninformedconsentwaswaivedbecauseofthe retrospectiveandobservationalnatureofourstudy. EMSOfWuhan

    WuhanisalargecityincentralChina,locatedonthe Correspondingauthor:Dr.YanZhao,EmergencyDepartment, ZhongnanHospitalofWuhanUniversity,Wuhan430071,China; Email:yz271l@gmailcom

    yangtzRiver,withapopulationof8,400,000andapopula

    tiondensityof947personspersquarekilometres.Thereare

    80provincialormunicipalhospitals.52ofwhichreceive patientstransportedbythelocalEMS.EMSofWuhanisa onetieredsystem.Whenl20(thephonenumberofChi

    neseEMS,iscalled.thecallcentredispatchesthenearest availableambulance.Afterinitialtreatment.thepatientmay betransportedtooneofthe52hospitals.EMSofWuhan includesoneEMScentreand17stations.15ofwhichare locatedinhospitals.Eachstationhasoneortwostandard ambulances,eachservinganareawithaneightkilometre.

    radius.EachambulanceisequippedwithanECGmachine,a mOnitor/defibrillatOr,arespiratorymachine,abagvalve

    ventilator,alaryngoscopeandstafledbyonedoctor,one nurse,onedriverandtwostretcherbearers.Theheadofthe teamisadoctor,whoisusuallyageneralpractitionertrained intheAmericanHcartAssociation'sAdvancedCardiacLife Support(ACLS)

    Asfarasweknow,theUtsteinstylehasnotbeen

    introducedintoChinayet.Thesamedispatchfotinhasbeen usedforallpatientsandthedataisnotclassifiedOrentered intoacomputer,makingitimpossibletotrackprehospital information.

    ZhongnanHospitalanditsEmergencyDepartment

    ZhongnanHospitalofWuhanUniversityisa1200

    bedteachinghospita1.Itisoneofthelargestpublictertiary hospitalsinWuhan.Ouremergencydepartmentisincharge ofemergencyskillstrainingforallemergencyphysiciansin JournalofGeriatricCardiologySeptember2009Vol6No3143 ourprovince.A11cardiacarrestpatientsaregivenadvanced cardiaclifesupportinouremergencydepartmentbyfull

    timeemergencydoctorsaccordingtothecontemporary

    protocols(2000and2005AmericanHeartAssociation GuidelinesforCardiopulmonaryResuscitation).Twoof thephysiciansarecertifiedAHAACLSinstructors.The physicianistheheadoftheteam.andatleasttwonurses arealsoinvolvedintheresuscitatiOn.0neofthenurses isresponsibleforrecordingtheresuscitativeprocess duringtheresuscitationastimeallows.Consultingdec

    torsareabletoarriveattheemergencydepartmentwithin 5mjnutes.

    Eligiblepatients

    Patientsreceivedbyouremergencydepartmentwere includedinthestudyiftheyhadsufferedOHCAandfailed toobtainreturntospontaneouscirculation.Patientswere excludediftheirarrestswererelatedtotrauma,electricshock, orintoxication.Patientsunderage18werealsoexcluded. Studydesign

    Theresuscitativeprocessonemergencyrecordswas reviewed.Thetimeoftheonsetofcardiacarrestwasalways unavailable,butinmostcasesitwasconsideredtobethe timethevictimwasfoundunresponsive.Timezerowasde. finedasthemomentthepatientpresentedtotheemergency department,andtherevivingtimewasthetimeofrestora- tionofspontaneouscirculation(ROSC).ROSCwasdefined asaspontaneousheartrategreaterthan60bpmandsys. tolicartefialbloodpressureabove90mmHg,withorwithout vasoactivedrugs.Thefollowinginformationwasobtained: thepatient'sage,sex,andshort.termoutcome,endotra- chealintubationandshockrdefibril1ationorelectrical conversion),drugsadministered,revivingtimeandcumula

    tivetime.Cumulativetime(timespentoneachpatientdur-

    ingtheresuscitationmultipliedbythenumberofdoctors andnurses,excludingintemdoctorsandnurses)wasused asanindicatoroftheresuscitativeeff0rtaspreviously described6.InthecaseofpatientswhoaccomplishedROSC andwereadmittedintoourhospital,thehospitalizatiOn courseswerereviewed.Short.termsurvivalwasdefinedas R0SCandadmissionintoourhospitalortransportationto anotherhospita1.Longtermsurviva1wasdefinedasbeing

    aliveatIeastl2hoursafteradmission.Thefollowinginfo

    marionwasobtainedfromin.patientrecords:lengthofhos- pitalstay.timeinthecriticalcareunit,timeonarespirator, timeincoma,complications.finaloutcome(deathor discharge).causeofdeathandcerebralperformancecat- egory(CPC)scoreofthosedischarged.

    Statisticalanalysis

    Forthecategoricalvariable,thechi-squaretest(or Fisher'sexacttestwhenappropriate)wasusedtocompare andestablishdifferencesbetweenthecharacteristicsofthe survivorsandthoseofthedead.Forcontinuousdata,nor. malitywastestedusingtheKolmogorovSmirnovmethod.

    Ifitwasupheld,Student'st-test(unpairedandtwotailed)

    wasusedandifnot.theMann.Whitneytestwasperformed. Fornormallydistributedcontinuousvariables,thedatawas expressedasmean4-standarddeviationfSD1.Forskewed continuousvariables,thedatawasexpressedasmedian [2575%interquartilerange(IQR)].Kaplan-Meiercurves wereusedtodetermineresuscitativepossibilitAUstatis

    ticswerecarriedoutusingtheStatisticalProgramforSocial Sciences(SPSS13.0forWindows;SPSSInc..Chicago.

Illinois).AtwotailedPvalue<0.05wasconsidered

    significant.

    Results

    Characteristiesofpatientsandresuscitativeprocess Overaperiodof6years,85patientsweretransported toouremergencydepartmentwhereCPRwascontinued afterunsuccessfulEMSresuscitation.Themeanagewas 62+17yearsand61(72%1patientsweremale.Themedian intervalbetweenthetimewhenthepatientwasfoundunre

    sponsiveandthetimewhenthepatientwastransportedto ourdepartmentwas30(IQR2055)min.Peripheralintrave

    nouslineshadbeenplacedintoantecubitalveinsforallthe patientsbeforeadmissiontoourdepartmentwhileonly2 patientshadbeenorotracheallyintubated.

    0fthe85patients,thirteen(15%1patientsaccom. plishedROSCinouremergencydepartment.Resuscitative possibilitydeclinedquickly(Fig.1),anditreachedzeroat around23minutes.Lessatropineandadrenalineweregiven topatientswithR0SC(Table1,.111erewerenosignificant differencesinage,sex,interval,shock,orcumulativetime spentbydoctorsandnursesbetweenpatientswithand withoutROSC(Table11.

    Hospitalcourse

    Ofthe13patientssuccessfullyresuscitatedinour emergencydepartment,onepatientwastransferredtoan- otherhospitalonherfamily'sinsistencewithoutadmission Time(rain)

    Fig.1Resuscitativepossibilityofpatientstransportedto ouremergencydepartment.13of85patientsaccomplished restorationofspontaneouscirculationsubsequently.

富镩量IsSa_d

    gusnsi'

    144JournalofGeriatricCardiologySeptember2009Vol6No3 toourhospita1.makinghersubsequentinformation untraceable.Ofthe12patientsadmitted.onepatient'shos. pita1recordwasunavailable.Fortheremainingl1patients. themedianstaywas2(IQR16,daysandtheywereinthe

    acutecareunitandsevenpatientsdiedwithintwodays afteradmission.Ofthese11patients.eightdiedafterwith. drawa1oftreatmentasaskedbytheirfamilies,onedieddue torefractoryhypotensionandonewasdischargedwitha CPCscoreof4.Thelastpatientwasdiagnosedwithmyo. cardialinfarction.underwentcoronaryarterystent placement,washospitalizedfor24daysanddischargedwith aCPCscoreof1.Fromthewholepopulationof85patients onlyonepatientwasdischargedwithagoodCPCscore(1%, 95%confidenceinterval0.036%,.

    Diseussion

    Wereviewedtheresuscitativeprocessandhospital courseofthepatientstransportedtoouremergencyde- partmentafterunsuccessfulbutcontinuedEMS

    resuscitatiOn.WehavefoundthatthecOntinuatiOnOfCPR isnotfutileandmayimproveoutcomes.Forshortterm outcomes.15%OfourpatientsaccomplishedR0SCinour emergencydepartment.Forlongtermoutcomes,1%Ofpa-

    tientsweredischargedwithfavorableneurologicoutcomes. WehavecomparedtheROSCrateandthedischargerateof ourstudywiththoseofotherpublishedstudies(Table2). Eisenburgereta1.reportedmuchbetteroutcomes,buttheir

patientscomprisedbothoutof-hospitalandin.hospital

    cardiacarrestpatients,whichmayskewtheiroutcomes.

    Comparedwiththerestofthestudies,ourresultswerewithin

    thesamerange.Atleasttwofactorsmayaccountforour

    results.First,differentcriteriaareusedtohelpEMSperson. nelmakethedecisiontotransportunsuccessfullyresusci.

    tatedOHCApatientsanditismoreofanintuitivedecision.

    Second.theunacceptableunsuccessfulEMSresuscita.

    tionratecouldmaketheROSCrateinouremergencyde-

    partmenthigher.Asfarasweknow,wedonothaveana.

    tionalorregionalregistryof0HCA:itiswidelybelieved

    thatnomorethan5%OHCApatientsareSuccessfullyre

    suscitatedbyEMS.OntheFirstForumofGuangzhouCat-

    diopulmonaryResuscitationheldinAugust2006,some

    Table1Characteristicsofpatientswithandwithoutrestorationofspontaneouscirculation(R

    OSC)intheemer-

    gencydepartmentafterunsuccessfulbutcontinuedEMScardiopulmonaryresuscitation Dataareexpressedasmean?SD,medianI25%

    75%interquartilerange(IQR)l,ornumber(percentage).

    Interval:theintervalbetweenthetimewhenthepatientwasfoundunresponsiveandthetimewhenthepatientwastransportedtoemergencydepartment

    Shock:def1brnlati0?orcardi0versi0?.

    Foralldata.morethan80%patients'informationwasavailable. Table2ComparisonofROSCand/orhospitalizedaliveratesanddischargeratesinpatientstransportedtOemer-

    gencydepartmentforcontinuingresuscitation

    ROSC:returnofspontaneouscirculationorrestorationofspontaneouscirculation;'Actualnumbershouldbelargerbecauseofadifferentresearchobjective;CI: confidenceinterval;NA:datanotavailable.

    JournalofGeriatricCardiologySeptember2009Vol6No3145

    C:hineseexpertsreportedthattheratewaslessthan1% throughoutthemainland,whichwasmuchlowerthanpre

    viousreports.Asforcomparison,onemetaanalysisofstud-

    iesindevelopedcountriesreporteda6.4%mediansurvival tohospitaldischargeforOHCApatientsinallrhythm groups..Otherwesternstudieshadalargedisparityinthis figure.rangingfrom8.2%to23.4%..Thefactthatonly 2%Ofourpatientswereorotracheallyintubatedappearsto beasignofinsufficientEMSeffort.Wecautiouslywith

    holdtheideathatwedidbetterresuscitation.becauseal- mostnoprehospitalinformationwasavailableforourstudy. Butwebelievethattheprehospitalresuscitativeeffortsare farfromoptimalinourcity.

    Withorwithoutadvancedlifesupportprocedures implemented.Morrisoneta1.7,proposedthatinpatients havinganOHCA,effortsshouldbeterminatedatthescene ifthereisnoROSC,noshocksareadministered,noby- standerCPRandthearrestisnotwitnessedbyemergency medicalservicespersonne1.Nevertheless,wethinkthatmis proposalshouldnotbecarriedoutinareaswhereprehospital CPRissub.optima1.PatientswithOHCAshouldbetrans

    portedtohospitalsbeforeprehospitaleffortsareseriously evaluated.

    Themedianintervalbetweenthetimewhenthepa

    tientwasfoundunresponsiveandthetimewhenthepa- tientwastransportedtoourdepartmentwas20min(TableI1 forshort.termsurvivors.Weuseunresponsivetimeinstead ofcollapsetime,becausethelatterisalwaysdesirablebut notapplicable.,Itisnotsurprisingthatmoreatropine andadrenaline(TableI1weregiventothepatientswhodid

    notsurvivesincephysiciansusemoremedicationsonthose patientswhofailtorespondtoresuscitativeef_f0rts.Ithas beenreportedthatanincreaseddoseofadrenalineisin- dicativeofpoorneurologicoutcome"andhighshort-term andlong.termmortality..Thefactthatmorethanhalfofthe patientsreceivedshockfdefibrillationorelectrical conversion)wasprobablypartlyduetoblinddefibrillations. Limitations

    Ourstudyhassomelimimtions.First,ourstudywasa retrospectiveone.Second,noinformationwasavailableon witness,initialrhythm,bystanderCPR,anyprehospital ROSC.ortimeofcollapse.TheUtsteinstyletemplate,a usefultoo1forassistingevaluationandcomparisonofCPR regionally,nationally,andworldwide,hasnotyetbeen

    introducedintoChina.Third.GuidelinesforCPRwereup- datedin2005andmayhaveinfluencedtheoutcomes.Last, therewasnolong.termfollow.upOfthepatientsdischarged. Conclusions

    ThisstudyshowsthatthecontinuationofCPRmay improveoutcomes,particularlywhenprehospitalCPRisnot optima1.WearecooperatingwiththeEMSofWuhan,de

    signingdouble-printOHCArecordsaccordingtotheUtstein templateandhopingtocollectcopiesoftheserecords. WebelievethecontinuationofCPRshouldbereevaluated

    inthefuturewhenprehospitalinformationCallbecombined within-hospitalinformation.

    Acknowledgments

    .

    Wehighlyappreciatethetremendousworkofallthe physiciansandnursesofouremergencydepartment.We

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