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© Borgis - Postępy Nauk Medycznych 6/2018, s. 308-313 | DOI: 10.25121/PNM.2018.31.6.308
*Klaudiusz Nadolny1, 2, Jerzy Robert Ladny1, Daniel Slezak3
The influence of emergency medical procedures and event circumstances on the acute effectiveness of resuscitation in out-of-hospital sudden cardiac arrest in adults
Wpływ udzielanych czynności medycznych a skuteczność resuscytacji z pozaszpitalnym nagłym zatrzymaniem krążenia u osób dorosłych
1Department of Emergency Medicine, Medical University of Bialystok, Poland
2University of Strategic Planning in Dabrowa Gornicza, Poland
3Emergency Medicine Workshop, Department of Emergency Medicine, Faculty of Health Sciences, Medical University of Gdansk, Poland
Streszczenie
Wstęp. Nagłe zatrzymanie krążenia jest poważnym zdarzeniem medycznym, które może wystąpić w najmniej oczekiwanym miejscu i czasie. Jest bardzo poważnym problemem medycznym i społecznym.
Cel pracy. Celem pracy była ocena udzielanych świadczeń medycznych u pacjentów, u których wystąpiło pozaszpitalne nagłe zatrzymanie krążenia i skuteczności powrotu parametrów życiowych.
Materiał i metody. Badanie kliniczno-kontrolne przeprowadzono na podstawie dokumentacji medycznej Pogotowia Ratunkowego w Katowicach za 2017 rok. Wyniki zaprezentowano za pomocą wskaźników struktury (liczebności i odsetki) oraz mediany i IQR. Do porównania grup pacjentów „ROSC” oraz „no ROSC” wykorzystano statystyki nieparametryczne: test χ2 Pearsona lub U Manna-Whitneya. Dla wszystkich analiz jako domyślny poziom istotności statycznej przyjęto wartość 0,05.
Wyniki. Do analizy włączono 1713 przypadków pozaszpitalnego NZK. Mężczyźni stanowili 63,68% (N = 1091), a kobiety jedynie 34,5% (N = 591). Kobiety były starsze niż mężczyźni (średnia wieku 69,5 vs 62,9 roku, p = 0,000). Natomiast częściej wykonywano defibrylację u mężczyzn niż u kobiet (p = 0,000). Najczęściej do wystąpienia pozaszpitalnego NZK dochodziło w warunkach domowych (p = 0,000), najczęściej w ciągu dnia (p = 0,000). Wyższy wskaźnik ROSC odnotowano, kiedy świadek udzielał pierwszej pomocy (35,6 vs. 31,41%, p = 0,08). Pacjenci z VF mieli większy wskaźnik ROSC niż z asystolią (56,27 vs. 24,95%, p = 0,000).
Wnioski. ROSC zależy od wykonywanych medycznych czynności ratunkowych na miejscu zdarzenia. Postępowanie zgodnie z aktualną wiedzą medyczną powoduje większy odsetek skuteczności resuscytacji.
Summary
Introduction. Sudden cardiac arrest is a serious medical event that may occur unexpectedly. It is a serious medical and social issue.
Aim. The aim of the study is an analysis of the relationship between the type of medical rescue actions taken and return of spontaneous circulation (ROSC) in adults.
Material and methods. The case-control study was based on the medical documentation of the Rescue Service in Katowice collected in 2017. The results have been presented by means of proportions (sample size and sampling rate), median and IQR. Non-parametric methods (Pearson’s chi-squared test or Mann-Whitney U test) were used to compare the group of ROSC-patients with the group of no-ROSC-patients. The default statistical significance adopted for the purpose of all analyses was 0.05.
Results. The analysis covered 1713 out-of-hospital sudden cardiac arrest (SCA) cases. Male patients constituted 63.68% (N = 1091) of the group, whereas female patients constituted only 34.5% (N = 591) of the cases. Women were older than men (69.5 vs. 62.9; p = 0.000). However, defibrillation was more frequently applied in men than in women (p = 0.000). In a majority of cases, SCA occurred in domestic conditions (p = 0.000) during the day (p = 0.000). ROSC was reported in 591 cases (34.51%). The ROSC rate was higher in cases when witnesses provided first aid to patients (35.6 vs. 31.41%; p = 0.08). The rate was also higher in patients with ventricular fibrillation than in patients with asystole (56.27 vs. 24.95%; p = 0.000).
Conclusions. ROSC depends on the emergency medical procedures actions performed at the place of incident. The ROSC rate in patients is significantly higher when procedures are performed according to the current medical knowledge.
INTRODUCTION
Sudden cardiac arrest (SCA) is a serious medical event that may occur unexpectedly. It is a serious medical and social issue (1). SCA may be caused by various factors (both diseases and traumas) and requires taking immediate rescue actions performed by witnesses as well as by qualified medical emergency teams. In Europe, SCA is diagnosed in 38/100 000 inhabitants per annum (2, 3), whereas in the USA, SCA is diagnosed in 76/100 000 per year (4). Globally, there are numerous registers of out-of-hospital SCA (5, 6).
The definition of SCA is closely related to the notion of sudden cardiac death (SCD). SCD is universally defined as a natural death from a cardiovascular cause presenting loss of consciousness and death within one hour from the occurrence of symptoms (the one-hour period is arbitrary) (7). In spite of the fact that SCA registers have recently indicated an increase in the return of spontaneous circulation (ROSC) rate in Europe and in the world, SCA mortality still remains incredibly high: only 10.6% of SCA patients survive to leave hospital (8).
Witnesses of the incidents play an important role in successful rescue actions. Prompt reaction and resuscitation performed by a third party increase the chances of ROSC (9). Ventricular fibrillation was the first rhythm diagnosed by the emergency medical team in only about 20-25% of cases (10). In such a numerous population that the USA has, shockable rhythms are reported in only 23% of patients, where the survival rate amounts to 22 vs. 8% as far as the non-shockable rhythms are concerned (11, 12). However, when the witness uses an AED (Automated External Defibrillator), the survival rate will reach from 59% up to 79% (13-15).
AIM
The aim of this research was the assessment of the effectiveness of emergency medical procedures performed by emergency medical teams in prehospital care in reference to the ROSC rate in the 2.7-million-population monitored by the Voivodeship Rescue Service (VRS) in Katowice.
MATERIAL AND METHODS
Study design and population
The case-control study was based on the medical documentation of the Emergency Medical Services (EMS) units of Voivodeship Rescue Service (VRS) in Katowice covering 2.7 million inhabitants and collected in 2017 (n = 254 673). The research involved exclusively individuals older than 18 years, with non-hospital SCA. After considering the above inclusion criteria, there were 1713 dispatch order forms (0.67% of all dispatch orders) involved in further research. Consent of the Bioethics Committee was not required.
Data collection and processing
Demographic data (i.e. gender, age, location, time of the day) of the incidents with non-hospital SCA were analyzed. Calls between emergency medical dispatchers and witnesses of the incidents were analyzed as far as first aid instructions and main reporting reason were concerned. Emergency medical teams were divided into two groups, i.e. teams with doctors and teams without doctors. In Poland, the only indicator of the system’s quality is the median of time from team dispatch to team arrival at destination. The median was calculated for both emergency priority codes: C-1 and C-2. Based on the emergency medical procedure forms, the actions of emergency medical teams were verified as far emergency medical procedures (endotracheal intubation, the use of suction pumps, defibrillation, the use of alternatives providing airway patency, the mechanism of cardiac arrest etc.) and ROSC were concerned. The case-control study did not cover actions performed after transfers of patients to intensive care units (ICU). No hospital medical procedures were analyzed.
Statistical analysis
Descriptive statistics involved the calculation of proportions (sample size and sampling rate for non-metric variables), and median, as well as IQR in the case of quantitative variables. Depending on the measurement scale, Pearson’s chi-squared test or Mann-Whitney U test were used to compare the group of ROSC-patients with the group of no-ROSC-patients. The model of logistic regression was applied to estimate the probability of ROSC. The dependent variable was the presence of ROSC (value: 1) or the absence of ROSC (value: 0). STATISTICA 13.1 (StaSoft® Inc.) and IBM® SPSS 24.0 software were used to analyze data. The default statistical significance adopted for the purpose of all analyses was 0.05.
RESULTS
All non-hospital SCA cases involved 1091 male individuals (63.68%) and 591 female individuals (34.5%). There were 31 patients (1.81%) with no gender reported in medical documentation. Moreover, the analyzed cases of non-hospital SCA included 1035 (60.42%) patients aged over 65 years (the age median 66.1 years). Female patients were older than male patients (age mean: 69.5 vs. 62.9; p = 0.000), which was true also for the group of patients aged over 65 years. However, defibrillation was more often performed in men than in women (p = 0.000) (tab. 1). What is more, defibrillation was more frequently performed in patients aged over 65 years than in younger patients (p = 0.011) (tab. 2).
Tab. 1. A comparative analysis of selected variables according to gender
VariableMale individualsFemale individualsP-value*
Age > 65 years538 (48.2%)319 (69.1%)0.000
Priority code 1 (urgent) 991 (90.09%)487 (82.4%)0.002
Ventilation frequency – ventilation bag641 (61.8%)335 (55.7%)0.017
Defibrillation270 (25.3%)92 (15.3%)0.000
Location (at home)704 (68.8%)434 (74.5%)0.025
Death 721 (67.2%)404 (67.5%)NS
*Pearson’s chi-squared test
Tab. 2. A comparative analysis of selected variables according to age
VariableAge > 65 yearsAge < 65 yearsP-value*
Defibrillation221 (21.35%)183 (26.99%)0.011
Location (at home)713 (68.8%) 471 (73.82%)NS
Priority code 1 (urgent)871 (84.1%)611 (90.1%)0.017
Total time from dispatch to arrival up to 8 minutes 414 (40%) 252 (37.16%)NS
Intubation521 (50.33%)371 (54.71%)NS
*Pearson’s chi-squared test
SCA most frequently occurred during the day (between 07.01 a.m. and 07.00 p.m.) (n = 1062; 61.99%). SCA cases were less frequently reported in the evenings and at night (between 07.01 p.m. and 07.00 a.m.) (n = 651; 38.01%).
Most non-hospital SCA cases occurred in domestic conditions (n = 1211; 70.69%), next in public places (n = 261; 15.23%) and at school (n = 3; 0.17%). Patients who suffered from SCA at home were older than patients with SCA that occurred outside their homes (age mean 65.8 vs. 63.8; p = 0.026). SCA in male patients occurred more frequently outside their homes than at home (p = 0.012) (tab. 3).
Tab. 3. A comparative analysis of selected variables according to incident location
VariableAt homeNot at homeP-value*
Defibillation234 (20.6%) 120 (25.6%)0.027
Death786 (66.13%)356 (69.7%)NS
Priority code 1 (urgent)1071 (88.1%)443 (88.4%)NS
Total time from dispatch to arrival up to 6 minutes497 (41.2%)204 (40.9%)NS
*Pearson’s chi-squared test
There was a witness of non-hospital SCA in 1141 cases (66.6%). Further 184 cases (10.74%) occurred in the presence of emergency medical teams. Other cases (n = 388; 22.65%) occurred without any witness.
According to the emergency medical documentation and the recordings of conversations with emergency medical dispatchers, there were some actions performed by the third person who witnessed the incident in 861 cases (50.26%). In 184 cases, the witnesses were emergency medical team members. Consequently, actions were taken in 1045 cases in total. However, patients did not receive any assistance in 668 cases of non-hospital SCA.

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otrzymano: 2018-11-05
zaakceptowano do druku: 2018-11-26

Adres do korespondencji:
*Klaudiusz Nadolny
Department of Emergency Medicine Medical University of Bialystok
37 Szpitalna Str., 15-295 Bialystok Poland
Phone: +48 513082398
E-mail: knadolny@wpr.pl

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