Improving Resuscitation Rates After Out-of-Hospital Cardiac Arrest

Improving Resuscitation Rates After Out-of-Hospital Cardiac ArrestIt's Complicated Article, see p 1262 I n June 1990, an international multidisciplinary meeting was held at Utstein Abbey, near Stavanger, Norway.At this meeting, by consensus, uniform terms and definitions for outcomes after out-of-hospital cardiac arrest (OHCA) resuscitation and terms and definitions for variables to be measured were agreed on.It is widely held that, if we can agree on how and what to measure in cases of OHCA, we can better understand those variables that are associated with higher survival rates, and test interventions to improve survival from this devastating condition.In 2014, an International Liaison Committee on Resuscitation consensus statement 1 updated the data elements and definitions to incorporate 5 data element domains, including system factors, dispatch factors, patient factors, process factors, and outcomes that were all important in understanding the landscape of OHCA. 1 A large number of well-conducted observational studies and registries have confirmed that those prehospital factors most associated with improved survival include cardiac arrest in a public place, prompt recognition by bystanders that the arrest has occurred, the provision of any (and preferably high-quality) cardiopulmonary resuscitation (CPR) by bystanders, the use of an automated external defibrillator (AED), and a brief, as opposed to a prolonged, time interval from the emergency medical services (EMS) activation until the arrival of professional rescuers.Somewhat frustratingly, many, if not most, randomized clinical trials conducted prehospital in patients with OHCA have failed to show any benefit from prehospital interventions that were expected to be effective at improving neurologically intact survival.These include the provision of defibrillators in the home for patients at high risk 2 ; the use of an impedance threshold device that was expected to improve the quality of myocardial and cerebral perfusion during CPR 3 ; the delay of ECG analysis by paramedics to allow high-quality CPR and brain and cardiac perfusion before a defibrillation shock 4 ; the use of antiarrhythmic drugs (amiodarone or lidocaine) versus placebo in shock-resistant ventricular fibrillation 5 ; the use of any intravenous drug therapy versus no intravenous drugs in advanced cardiac life support 6 ; and an extremely small absolute benefit (<0.5% absolute improvement in neurologically intact survival) after intravenous epinephrine.7 The study by Chocron and colleagues 8 in this issue of Circulation addresses 1 element of the chain of survival in understanding the events that can contribute to or detract from survival after OHCA.The metaphor was first published in 1981 in a newsletter of CPR for Citizens in Orlando, Florida, and subsequently published in the Journal of Emergency Medical Services and adopted by the American Heart Association, and eventually worldwide.9 In the study by Chocron et al, the elements of OHCA associated with improved survival that are related to patient or EMS system factors included witnessed

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