Association of Intra-arrest Transport vs Continued On-Scene Resuscitation With Survival to Hospital Discharge Among Patients With Out-of-Hospital Cardiac Arrest

Abstract

IMPORTANCE There is wide variability among emergency medical systems (EMS) with respect to transport to hospital during out-of-hospital cardiac arrest (OHCA) resuscitative efforts. The benefit of intra-arrest transport during resuscitation compared with continued on-scene resuscitation is unclear.OBJECTIVE To determine whether intra-arrest transport compared with continued on-scene resuscitation is associated with survival to hospital discharge among patients experiencing OHCA. DESIGN, SETTING, AND PARTICIPANTSCohort study of prospectively collected consecutive nontraumatic adult EMS-treated OHCA data from the Resuscitation Outcomes Consortium (ROC) Cardiac Epidemiologic Registry (enrollment, April 2011-June 2015 from 10 North American sites; follow-up until the date of hospital discharge or death [regardless of when either event occurred]). Patients treated with intra-arrest transport (exposed) were matched with patients in refractory arrest (at risk of intra-arrest transport) at that same time (unexposed), using a time-dependent propensity score. Subgroups categorized by initial cardiac rhythm and EMS-witnessed cardiac arrests were analyzed.EXPOSURES Intra-arrest transport (transport initiated prior to return of spontaneous circulation), compared with continued on-scene resuscitation. MAIN OUTCOMES AND MEASURESThe primary outcome was survival to hospital discharge, and the secondary outcome was survival with favorable neurological outcome (modified Rankin scale <3) at hospital discharge. RESULTSThe full cohort included 43 969 patients with a median age of 67 years (interquartile range, 55-80), 37% were women, 86% of cardiac arrests occurred in a private location, 49% were bystander-or EMS-witnessed, 22% had initial shockable rhythms, 97% were treated by out-of-hospital advanced life support, and 26% underwent intra-arrest transport. Survival to hospital discharge was 3.8% for patients who underwent intra-arrest transport and 12.6% for those who received on-scene resuscitation. In the propensity-matched cohort, which included 27 705 patients, survival to hospital discharge occurred in 4.0% of patients who underwent intra-arrest transport vs 8.5% who received on-scene resuscitation (risk difference, 4.6% [95% CI, 4.0%-5.1%]). Favorable neurological outcome occurred in 2.9% of patients who underwent intra-arrest transport vs 7.1% who received on-scene resuscitation (risk difference, 4.2% [95% CI, 3.5%-4.9%]). Subgroups of initial shockable and nonshockable rhythms as well as EMS-witnessed and unwitnessed cardiac arrests all had a significant association between intra-arrest transport and lower probability of survival to hospital discharge.CONCLUSIONS AND RELEVANCE Among patients experiencing out-of-hospital cardiac arrest, intra-arrest transport to hospital compared with continued on-scene resuscitation was associated with lower probability of survival to hospital discharge. Study findings are limited by potential confounding due to observational design.

Outcome in refractory out-of-hospital cardiac arrest before and after implementation of an ECPR protocol

“…28 Another study found that intra-arrest transport was found to be associated with a lower probability of survival and a worse neurologic outcome. 29 Several studies have considered the balance of on-site ALS and transport, finding that 90% of survivors achieved ROSC within 16 min 26 to 24 min, 27 and Kim et al concluded that 21 min was the best time to initiate transport to the hospital. 30 It may not be possible within a group of patients to predict who might benefit from prolonged onscene ALS or transport with ongoing ALS.…”

Assessing need for extracorporeal cardiopulmonary resuscitation for out‐of‐hospital cardiac arrest using Power BI for data visualisation

“…The decision to transport a patient in cardiac arrest for ECPR must not compromise the quality of CCPR. 24 Appropriate ECPR-selection criteria and the optimal timing of transfer may be identified from wellconducted randomised trials, including currently recruiting trials, 25 but given the substantial resource cost of ECPR, cost-benefit must also be established. The modelling described here allows for meaningful needs assessment and planning to provide assurance prior to commencement of ECPR programmes.…”

“…A critical consideration of any aspiring ECPR programme is to achieve at least equivalent outcomes with those currently attained by conventional measures. The decision to transport a patient in cardiac arrest for ECPR must not compromise the quality of CCPR 24 . Appropriate ECPR‐selection criteria and the optimal timing of transfer may be identified from well‐conducted randomised trials, including currently recruiting trials, 25 but given the substantial resource cost of ECPR, cost–benefit must also be established.…”

2020 Korean Guidelines for Cardiopulmonary Resuscitation. Part 1. Update process and highlights

“…A few observational studies have been conducted to evaluate the effect of the duration of on-scene CPR; however, no large scale randomized study has been conducted on that topic yet. 19,20 The duration of on-site CPR should be determined considering a variety of factors, including the training level of the emergency medical team providing resuscitation (BLS or ALS level), elapsed time from cardiac arrest, and transport time to the hospital. The 2020 guidelines recommend considering transporting the patient to the hospital if restoration of spontaneous circulation is not achieved after 6 minutes of on-site CPR if the resuscitation team can only perform BLS or after 10 minutes of on-site CPR if resuscitation team can perform ALS.…”