Drones can be used to provide dispatch centres with on-site photos before arrival of EMS in time critical incidents.

BACKGROUND: Drones are able to deliver automated external defibrillators in cases of out-of-hospital cardiac arrest (OHCA) but can be deployed for other purposes. Our aim was to evaluate the feasibility of sending live photos to dispatch centres before arrival of other units during time-critical incidents. METHODS: In this retrospective observational study, the regional dispatch centre implemented a new service using five existing AED-drone systems covering an estimated 200000 inhabitants in Sweden. Drones were deployed automatically over a 4-month study period (December 2022-April 2023) in emergency calls involving suspected OHCAs, traffic accidents and fires in buildings. Upon arrival at the scene, an overhead photo was taken and transmitted to the dispatch centre. Feasibility of providing photos in real time, and time delays intervals were examined. RESULTS: Overall, drones were deployed in 59/440 (13%) of all emergency calls: 26/59 (44%) of suspected OHCAs, 20/59 (34%) of traffic accidents, and 13/59 (22%) of fires in buildings. The main reasons for non-deployment were closed airspace and unfavourable weather conditions (68%). Drones arrived safely at the exact location in 58/59 cases (98%). Their overall median response time was 3:49 min, (IQR 3:18-4:26) vs. emergency medical services (EMS), 05:51 (IQR: 04:29-08:04) p-value for time difference between drone and EMS =0,05. Drones arrived first on scene in 47/52 cases (90%) and the largest median time difference was found in suspected OHCAs 4:10 min, (IQR: 02:57-05:28). The time difference in the 5/52 (10%) cases when EMS arrived first the time difference was 5:18 minutes (IQR 2:19-7:38), p=NA. Photos were transmitted correctly in all 59 alerts. No adverse events occurred. CONCLUSION: In a newly implemented drone dispatch service, drones were dispatched to 13% of relevant EMS calls. When drones were dispatched, they arrived at scene earlier than EMS services in 90% of cases. Drones were able to relay photos to the dispatch centre in all cases. Although severely affected by closed airspace and weather conditions, this novel method may facilitate additional decision-making information during time-critical incidents.

Characteristics and motivational factors for joining a lay responder system dispatch to out-of-hospital cardiac arrests.

BACKGROUND: There has been in increase in the use of systems for organizing lay responders for suspected out-of-hospital cardiac arrests (OHCAs) dispatch using smartphone-based technology. The purpose is to increase survival rates; however, such systems are dependent on people's commitment to becoming a lay responder. Knowledge about the characteristics of such volunteers and their motivational factors is lacking. Therefore, we explored characteristics and quantified the underlying motivational factors for joining a smartphone-based cardiopulmonary resuscitation (CPR) lay responder system. METHODS: In this descriptive cross-sectional study, 800 consecutively recruited lay responders in a smartphone-based mobile positioning first-responder system (SMS-lifesavers) were surveyed. Data on characteristics and motivational factors were collected, the latter through a modified version of the validated survey "Volunteer Motivation Inventory" (VMI). The statements in the VMI, ranked on a Likert scale (1-5), corresponded to(a) intrinsic (an inner belief of doing good for others) or (b) extrinsic (earning some kind of reward from the act) motivational factors. RESULTS: A total of 461 participants were included in the final analysis. Among respondents, 59% were women, 48% between 25 and 39 years of age, 37% worked within health care, and 66% had undergone post-secondary school. The most common way (44%) to learn about the lay responder system was from a CPR instructor. A majority (77%) had undergone CPR training at their workplace. In terms of motivation, where higher scores reflect greater importance to the participant, intrinsic factors scored highest, represented by the category values (mean 3.97) followed by extrinsic categories reciprocity (mean 3.88) and self-esteem (mean 3.22). CONCLUSION: This study indicates that motivation to join a first responder system mainly depends on intrinsic factors, i.e. an inner belief of doing good, but there are also extrinsic factors, such as earning some kind of reward from the act, to consider. Focusing information campaigns on intrinsic factors may be the most important factor for successful recruitment. When implementing a smartphone-based lay responder system, CPR instructors, as a main information source to potential lay responders, as well as the workplace, are crucial for successful recruitment.

National coverage of out-of-hospital cardiac arrests using automated external defibrillator-equipped drones - A geographical information system analysis.

BACKGROUND: Early defibrillation is essential for increasing the chance of survival in out-of-hospital-cardiac-arrest (OHCA). Automated external defibrillator (AED)-equipped drones have a substantial potential to shorten times to defibrillation in OHCA patients. However, optimal locations for drone deployment are unknown. Our aims were to find areas of high incidence of OHCA on a national level for placement of AED-drones, and to quantify the number of drones needed to reach 50, 80, 90 and 100% of the target population within eight minutes. METHODS: This is a retrospective observational study of OHCAs reported to the Swedish Registry for Cardiopulmonary Resuscitation between 2010-2018. Spatial analyses of optimal drone placement were performed using geographical information system (GIS)-analyses covering high-incidence areas (>100 OHCAs in 2010-2018) and response times. RESULTS: 39,246 OHCAs were included. To reach all OHCAs in high-incidence areas with AEDs delivered by drone or ambulance within eight minutes, 61 drone systems would be needed, resulting in overall OHCA coverage of 58.2%, and median timesaving of 05:01 (min:sec) [IQR 03:22-06:19]. To reach 50% of the historically reported OHCAs in <8 min, 21 drone systems would be needed; for 80%, 366; for 90%, 784, and for 100%, 2408. CONCLUSIONS: At a national level, GIS-analyses can identify high incidence areas of OHCA and serve as tools to quantify the need of AED-equipped drones. Use of only a small number of drone systems can increase national coverage of OHCA substantially. Prospective real-life studies are needed to evaluate theoretically optimized suggestions for drone placement.

Different forms of bystander cardiopulmonary resuscitation in out-of-hospital cardiac arrest.

Out-of-hospital cardiac arrest (OHCA) is a major cause of death in the Western world with an estimated number of 275 000 treated with resuscitation attempts by the Emergency Medical Services (EMS) in Europe each year. Overall survival rates remain low, and most studies indicate that around 1 out 10 will survive to 30 days. Amongst the strongest factors associated with survival in OHCA is first recorded rhythm amendable to defibrillation, early defibrillation and prompt initiation of cardiopulmonary resuscitation (CPR). Overall, CPR started prior to EMS arrival has repeatedly been shown to be associated with survival rates 2-3 times higher compared with no such initiation. The primary goal of CPR is to generate sufficient blood flow to vital organs, mainly the brain and heart, until restoration of spontaneous circulation can be achieved. Barriers to the initiation of CPR by bystanders in OHCA include fear of being incapable, causing harm, and transmission of infectious diseases. Partly due to these barriers, and low rates of CPR, the concept of CPR with compression only was proposed as a simpler form of resuscitation with the aim to be more widely accepted by the public in the 1990s. But how reliable is the evidence supporting this simpler form of CPR, and are the outcomes after CO-CPR comparable to standard CPR?

Incidence and characteristics of drowning in Sweden during a 15-year period.

AIM: Drowning is a global health problem and deeper knowledge about the extent and causes is of utmost importance for implementing preventative actions. The aim of this study was to describe the incidence and characteristics of drowning in Sweden over time, including both non-fatal and fatal cases. METHODS: All cases identified as drowning (ICD-10 coding) at a national level in Sweden between 2003-2017 were collected. Three sources of data from the Swedish National Board of Health and Welfare were extracted via the Cause of Death Register and the National Patient Register. RESULTS: Over 15 years, a total of 6609 cases occurred, resulting in an annual incidence of 4.66 per 100 000. The median age was 49 years (IQR 23-67) and 67% were males. Non-fatal drownings represented 51% (n = 3363), with an overall non-fatal to fatal ratio of 1:1, this being 8:1 for children (0-17 years of age). Non-fatal cases were more often female (36% vs. 30%; p < 0.001), younger 30 (IQR 10-56) vs. 60 (IQR: 45-72) (p < 0.001) and of unintentional nature (81% vs. 55%; p < 0.001). The overall incidence decreased over time from 5.6 to 4.1 per 100 000 (p < 0.001). The highest rate of 30-day survival was found in females 0-17 years (94%, 95% CI 91.1-95.5) and the lowest in males >66 years (28.7%, 95% CI 26.2-31.2). Although the incidence in children 0-4 years increased from 7.4 to 8.1 per 100 000 (p < 0.001), they demonstrated the highest non-fatal to fatal ratio (13:1). CONCLUSION: Drowning is declining but remains a consistent and underestimated public-health problem. Non-fatal drowning cases represent about half of the burden and characteristics differ from fatal drowning cases, being younger, more often female and of unintentional nature.

The use of drones and a machine-learning model for recognition of simulated drowning victims-A feasibility study.

BACKGROUND: Submersion time is a strong predictor for death in drowning, already 10 min after submersion, survival is poor. Traditional search efforts are time-consuming and demand a large number of rescuers and resources. We aim to investigate the feasibility and effectiveness of using drones combined with an online machine learning (ML) model for automated recognition of simulated drowning victims. METHODS: This feasibility study used photos taken by a drone hovering at 40 m altitude over an estimated 3000 m2 surf area with individuals simulating drowning. Photos from 2 ocean beaches in the south of Sweden were used to (a) train an online ML model (b) test the model for recognition of a drowning victim. RESULTS: The model was tested for recognition on n = 100 photos with one victim and n = 100 photos with no victims. In drone photos containing one victim (n = 100) the ML model sensitivity for drowning victim recognition was 91% (95%CI 84.9%-96.2%) with a median probability score that the finding was human of 66% (IQR 52-71). In photos with no victim (n = 100) the ML model specificity was 90% (95%CI: 83.9%-95.6%). False positives were present in 17.5% of all n = 200 photos but could all be ruled out manually as false objects. CONCLUSIONS: The use of a drone and a ML model was feasible and showed satisfying effectiveness in identifying a submerged static human simulating drowning in open water and favorable environmental conditions. The ML algorithm and methodology should be further optimized, again tested and validated in a real-life clinical study.

Drone delivery of an automated external defibrillator - a mixed method simulation study of bystander experience.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) affects some 275,000 individuals in Europe each year. Time from collapse to defibrillation is essential for survival. As emergency medical services (EMS) response times in Sweden have increased, novel methods are needed to facilitate early treatment. Unmanned aerial vehicles (i.e. drones) have potential to deliver automated external defibrillators (AED). The aim of this simulation study was to explore bystanders' experience of a simulated OHCA-situation where a drone delivers an AED and how the situation is affected by having one or two bystanders onsite. METHODS: This explorative simulation study used a mixed methodology describing bystanders' experiences of retrieving an AED delivered by a drone in simulated OHCA situations. Totally eight participants were divided in two groups of bystanders a) alone or b) in pairs and performed CPR on a manikin for 5 minutes after which an AED was delivered by a drone at 50 m from the location. Qualitative data from observations, interviews of participants and video recordings were analysed using content analysis alongside descriptive data on time delays during bystander interaction. RESULTS: Three categories of bystander experiences emerged: 1) technique and preparedness, 2) support through conversation with the dispatcher, and 3) aid and decision-making. The main finding was that retrieval of an AED as delivered by a drone was experienced as safe and feasible for bystanders. None of the participants hesitated to retrieve the AED; instead they experienced it positive, helpful and felt relief upon AED-drone arrival and were able to retrieve and attach the AED to a manikin. Interacting with the AED-drone was perceived as less difficult than performing CPR or handling their own mobile phone during T-CPR. Single bystander simulation introduced a significant hands-off interval when retrieving the AED, a period lasting 94 s (range 75 s-110 s) with one participant compared to 0 s with two participants. CONCLUSION: The study shows that it made good sense for bystanders to interact with a drone in this simulated suspected OHCA. Bystanders experienced delivery of AED as safe and feasible. This has potential implications, and further studies on bystanders' experiences in real cases of OHCA in which a drone delivers an AED are therefore necessary.

Experiences and outcome from the implementation of a national Swedish automated external defibrillator registry.

BACKGROUND: Early cardiopulmonary resuscitation (CPR) and defibrillation with an Automated External Defibrillator (AED) increase survival from out-of-hospital cardiac arrest (OHCA). Although international guidelines recommend the use of AED registries to increase AED use, little is known about implementation. The aim of this paper is to describe the development of a national AED registry, to analyse the coverage and barriers to register AEDs. METHODS: The Swedish AED Registry (SAEDREG) was initiated in 2009 with the purpose of gathering the data of all public AEDs in Sweden. Data on all AEDs between 2013 and 2016 were included in the study. Additionally, data of non-registered AEDs was collected in one region using a survey to AED owners focusing on AED functionality. RESULTS: The number of AEDs doubled between 2013-2016. A total of 6703 AEDs (30%) were removed due to unavailability of validation. At the end of 2016, AEDs were most frequently registered in offices and workplaces, 45% (n = 7241) followed by shops, 7% (n = 1200). In the Gotland region, 218 AEDs, 57% (n = 124) were registered in the SAEDREG. Of n = 94 Non-registered AED functionality was high, the main reason not to register was unawareness of the SAEDREG, 74.5%. Of those aware of the register but not having registered, 25% stated "hard to register" as cause. CONCLUSIONS: A national AED registry may gather information of AEDs on a national level. Although numbers have doubled between 2013-2016 in Sweden, a large proportion is still non-registered. More awareness of the registry and easier registration process is needed. General AED functionality seems high regardless of registered or non-registered AEDs. A key area for future research may be to use AED-registers to ascertain effectiveness of AED programs in terms of actual patient outcome.

The challenges and possibilities of public access defibrillation.

Out-of-hospital cardiac arrest (OHCA) is a major health problem that affects approximately four hundred and thousand patients annually in the United States alone. It is a major challenge for the emergency medical system as decreased survival rates are directly proportional to the time delay from collapse to defibrillation. Historically, defibrillation has only been performed by physicians and in-hospital. With the development of automated external defibrillators (AEDs), rapid defibrillation by nonmedical professionals and subsequently by trained or untrained lay bystanders has become possible. Much hope has been put to the concept of Public Access Defibrillation with a massive dissemination of public available AEDs throughout most Western countries. Accordingly, current guidelines recommend that AEDs should be deployed in places with a high likelihood of OHCA. Despite these efforts, AED use is in most settings anecdotal with little effect on overall OHCA survival. The major reasons for low use of public AEDs are that most OHCAs take place outside high incidence sites of cardiac arrest and that most OHCAs take place in residential settings, currently defined as not suitable for Public Access Defibrillation. However, the use of new technology for identification and recruitment of lay bystanders and nearby AEDs to the scene of the cardiac arrest as well as new methods for strategic AED placement redefines and challenges the current concept and definitions of Public Access Defibrillation. Existing evidence of Public Access Defibrillation and knowledge gaps and future directions to improve outcomes for OHCA are discussed. In addition, a new definition of the different levels of Public Access Defibrillation is offered as well as new strategies for increasing AED use in the society.

Intensive care admissions due to poisoning.

BACKGROUND: Poisoning represents a significant part of admissions to intensive care units. The aim of this nationwide study was to describe recent national quality register data of demographics and mortality for these patients. METHOD: A retrospective national observational study including all patients over 19 years admitted to an ICU in Sweden, between 1 January 2010 and 31 December 2011, with an ICD-10 code for poisoning. The data were collected from three national registers (The Swedish Intensive Care Register, The National Patient Register, and The Cause of Death Register). RESULTS: The incidence of ICU-treated poisonings was 43/100,000. Twenty-one per cent (n = 8155) of all poisoned patients seeking medical care were admitted to the ICU. Their median age was 38 years (q1-q3: 26-51), as many men as women and 46.5% (n = 3790) had a previous registered poisoning. A mix of different substances was the most common type of suspected poisoning (29.7%, n = 2424). The in-hospital mortality was 1.9% and was correlated to invasive mechanical ventilation (OR 6.91 CI 95% 4.59-10.42), age > 40 (OR 4.54 CI 95% 2.86-7.21) and no previous hospitalisation for poisoning (OR 3.23 CI 95% 2.06-5.07). For 78.3% (n = 119) of the deceased patients, the fatal poisoning was their first diagnosed poisoning. The 30-day mortality was 2.7%, a majority died from poisoning (P < 0.01). CONCLUSION: In Sweden, patients treated in the ICU due to poisoning represent a fifth of all poisoned patients seeking medical care. Older men with no previous poisoning were considered a high-risk group.

Drones may be used to save lives in out of hospital cardiac arrest due to drowning.

BACKGROUND: Drowning leading to out-of-hospital cardiac arrest (OHCA) and death is a major public health concern. Submersion with duration of less than 10min is associated with favorable neurological outcome and nearby bystanders play a considerable role in rescue and resuscitation. Drones can provide a visual overview of an accident scene, their potential as lifesaving tools in drowning has not been evaluated. AIM: The aim of this simulation study was to evaluate the efficiency of a drone for providing earlier location of a submerged possible drowning victim in comparison with standard procedure. METHOD: This randomized simulation study used a submerged manikin placed in a shallow (<2m) 100×100-m area at Tylösand beach, Sweden. A search party of 14 surf-lifeguards (control) was compared to a drone transmitting video to a tablet (intervention). Time from start to contact with the manikin was the primary endpoint. RESULTS: Twenty searches were performed in total, 10 for each group. The median time from start to contact with the manikin was 4:34min (IQR 2:56-7:48) for the search party (control) and 0:47min (IQR 0:38-0:58) for the drone-system (intervention) respectively (p<0.001). The median time saved by using the drone was 3:38min (IQR 2:02-6:38). CONCLUSION: A drone transmitting live video to a tablet is feasible, time saving in comparison to traditional search parties and may be used for providing earlier location of submerged victims at a beach. Drone search can possibly contribute to earlier onset of CPR in drowning victims.

Medical versus non medical etiology in out-of-hospital cardiac arrest-Changes in outcome in relation to the revised Utstein template.

INTRODUCTION: The Utstein-style recommendations for reporting etiology and outcome in out-of-hospital cardiac arrest (OHCA) from 2004 have recently been revised. Among other etiologies a medical category is now introduced, replacing the cardiac category from Utstein template 2004. AIM: The aim of this study is to describe characteristics and temporal trends from reporting OHCA etiology according to the revised Utstein template 2014 in regards to patient characteristics and 30-day survival rates. METHODS: This registry study is based on consecutive OHCA cases reported from the Emergency medical services (EMS) to the Swedish Registry of Cardiopulmonary Resuscitation (SRCR) 1992-2014. Characteristics, including a presumed cardiac etiology in Utstein template 2004, were transcribed to a medical etiology in Utstein template 2014. RESULTS: Of a total of n=70,846 cases, 92% were categorized as having a medical etiology and 8% as having a non-medical cause. Using the new classifications, the 30-day survival rate has significantly increased over a 20-year period from 4.7% to 11.0% in the medical group and from 3% to 9.9% in the non-medical group (p≤0.001). Trauma was the most common cause in OHCA of a non-medical etiology (26%) with a 30-day survival rate of 3.4% whilst drowning and drug overdose had the highest survival rates (14% and 10% respectively). CONCLUSION: Based on Utstein 2014 categories of etiology, overall survival after OHCA with a medical etiology has more than doubled in a 20-year period and tripled for non-medical cases. Patients with a medical etiology found in a shockable rhythm have the highest chance of survival. There is great variability in characteristics among non-medical cases.

Unmanned aerial vehicles (drones) in out-of-hospital-cardiac-arrest.

BACKGROUND: The use of an automated external defibrillator (AED) prior to EMS arrival can increase 30-day survival in out-of-hospital cardiac arrest (OHCA) significantly. Drones or unmanned aerial vehicles (UAV) can fly with high velocity and potentially transport devices such as AEDs to the site of OHCAs. The aim of this explorative study was to investigate the feasibility of a drone system in decreasing response time and delivering an AED. METHODS: Data of Global Positioning System (GPS) coordinates from historical OHCA in Stockholm County was used in a model using a Geographic Information System (GIS) to find suitable placements and visualize response times for the use of an AED equipped drone. Two different geographical models, urban and rural, were calculated using a multi-criteria evaluation (MCE) model. Test-flights with an AED were performed on these locations in rural areas. RESULTS: In total, based on 3,165 retrospective OHCAs in Stockholm County between 2006-2013, twenty locations were identified for the potential placement of a drone. In a GIS-simulated model of urban OHCA, the drone arrived before EMS in 32 % of cases, and the mean amount of time saved was 1.5 min. In rural OHCA the drone arrived before EMS in 93 % of cases with a mean amount of time saved of 19 min. In these rural locations during (n = 13) test flights, latch-release of the AED from low altitude (3-4 m) or landing the drone on flat ground were the safest ways to deliver an AED to the bystander and were superior to parachute release. DISCUSSION: The difference in response time for EMS between urban and rural areas is substantial, as is the possible amount of time saved using this UAV-system. However, yet another technical device needs to fit into the chain of survival. We know nothing of how productive or even counterproductive this system might be in clinical reality. CONCLUSIONS: To use drones in rural areas to deliver an AED in OHCA may be safe and feasible. Suitable placement of drone systems can be designed by using GIS models. The use of an AED equipped drone may have the potential to reduce time to defibrillation in OHCA.

Out-of-hospital cardiac arrest: 10 years of progress in research and treatment.

Cardiac disease is the most common cause of mortality in Western countries, with most deaths due to out-of-hospital cardiac arrest (OHCA). In Sweden, 5000-10 000 OHCAs occur annually. During the last decade, the time from cardiac arrest to start of cardiopulmonary resuscitation (CPR) and defibrillation has increased, whereas survival has remained unchanged or even increased. Resuscitation of OHCA patients is based on the 'chain-of-survival' concept, including early (i) access, (ii) CPR, (iii) defibrillation, (iv) advanced cardiac life support and (v) post-resuscitation care. Regarding early access, agonal breathing, telephone-guided CPR and the use of 'track and trigger systems' to detect deterioration in patients' condition prior to an arrest are all important. The use of compression-only CPR by bystanders as an alternative to standard CPR in OHCA has been debated. Based on recent findings, guidelines recommend telephone-guided chest compression-only CPR for untrained rescuers, but trained personnel are still advised to give standard CPR with both compressions and ventilation, and the method of choice for this large group remains unclear and demands for a randomized study. Data have shown the benefit of public access defibrillation for dispatched rescuers (e.g. police and fire fighters) but data are not as strong for the use of automated defibrillators (AEDs) by trained or untrained rescuers. Postresuscitation, use of therapeutic hypothermia, the importance of specific prognostic survival factors in the intensive care unit and the widespread use of percutaneous coronary intervention have all been considered. Despite progress in research and improved treatment regimens, most patients do not survive OHCA. Particular areas of interest for improving survival include (i) identification of high-risk patients prior to their arrest (e.g. early warning symptoms and genes); (ii) increased use of bystander CPR training (e.g. in schools) and simplified CPR techniques; (iii) better identification of high-incidence sites and better recruitment of AEDs (via mobile phone solutions?); (iv) improved understanding of the use of therapeutic hypothermia; (v) determining which patients should undergo immediate coronary angiography on hospital admission; and (vi) clarifying the importance of extracorporeal membrane oxygenation during CPR.

A case report of systemic capillary leak syndrome (Clarkson's disease).

Systemic capillary leak syndrome (SCLS) is a very rare disorder also known as Clarkson's disease. The condition is characterized by recurrent episodes of severe capillary hyperpermeability resulting in severe hemoconcentration, hypoalbuminemia, hypovolemia and shock. We describe a 41-year-old previously healthy man who was admitted to hospital on several occasions with rapidly developing hypovolemic shock accompanied by extreme hemoconcentration and hypoalbuminemia. Our case is similar to other reports describing patients with SCLS where the initial suspicions have been pointing towards septic shock. He received a combination of prophylactic treatment with theophylline, beta-agonists, immunoglobulins and statins but eventually died after a severe episode of SCLS that ended with recurrent cardiac arrest. Clinical autopsy revealed pulmonary edema and acute and chronical organic fluid overload. SCLS should be kept in mind when treating patients suffering from attacks of severe idiopathic edema and mimics recurrent septic shock where no pathogen is found. The pathogenesis is unknown and the attacks may be lethal.

Tuition of emergency medical dispatchers in the recognition of agonal respiration increases the use of telephone assisted CPR.

OBJECTIVES: Bystanders cardiopulmonary resuscitation (CPR) increases survival in out-of-hospital cardiac arrest (OHCA). Emergency medical dispatchers (EMDs) can provide even totally inexperienced bystanders with instructions by telephone on how to resuscitate victims (T-CPR) until the emergency medical services (EMS) arrive. Agonal respiration makes it difficult for EMDs to identify cardiac arrests (CAs) which will prevent or delay initiation of T-CPR. The aim of this investigation was to study if tuition of EMDs can improve their ability to identify agonal respiration in OHCA to allow for more frequent offers of T-CPR. METHODS: An observational study was made in 2004 and subsequently, a repeat study was made in 2006. All OHCA (n=315 in 2004, n=255 in 2006) in the Stockholm region reported to the Swedish Cardiac Arrest Register were included and all corresponding EMS reports were reviewed. Emergency calls were recorded during the event. Witnessed cases of OHCA (n=76 in both 2004 and 2006) were analyzed using a structured data collection tool. RESULTS: The frequency of offered T-CPR to all bystanders of OHCA in 2004 was 47%. After special tuition on agonal respiration in OHCA it rose to 68% in 2006 (p=0.01). An even more marked rise was observed in OHCA cases with agonal respiration. In 2004 T-CPR was offered in 23% of these situations whereas the corresponding figures in 2006 had risen to 56% (p=0.006). CONCLUSIONS: Teaching EMDs to understand and recognize bystander descriptions of agonal respiration in patients with OHCA has resulted in a significant increase in offers of T-CPR in these situations.

Aspects on the increase in bystander CPR in Sweden and its association with outcome.

AIM: To describe changes in the proportion of bystanders performing cardiopulmonary resuscitation (CPR) in out of hospital cardiac arrest (OHCA) in Sweden and to study the impact of bystander CPR on ventricular fibrillation and on survival during various times. PATIENTS AND METHODS: All patients who suffered from OHCA in Sweden in whom CPR was attempted and who were included in the Swedish cardiac arrest register (SCAR) between 1992 and 2005. Crew witnessed cases were excluded. RESULTS: In all 34,125 patients were included in the survey. Among witnessed OHCA the proportion of patients receiving bystander CPR increased from 40% in 1992 to 55% in 2005 (p<0.0001). In non-witnessed OHCA the corresponding proportion increased from 22% to 44% (p<0.0001). There was a significant increase in bystander CPR regardless of age, sex and place. The increase was only found when CPR was performed by lay persons (21% in 1992 to 40% in 2005; p<0.0001). Bystander CPR was associated with an increased proportion of patients found in a shockable rhythm and a lower number of shocks to receive return of spontaneous circulation. Bystander CPR was associated with a similar increase in survival early and late in the evaluation. CONCLUSION: There was a marked increase in bystander CPR in OHCA, when performed by lay persons, during the last 14 years in Sweden. Bystander CPR was associated with positive effects both on ventricular fibrillation and survival.

Changing health behaviors to improve health outcomes after angioplasty: a randomized trial of net present value versus future value risk communication.

Patients who have undergone angioplasty experience difficulty modifying at-risk behaviors for subsequent cardiac events. The purpose of this study was to test whether an innovative approach to framing of risk, based on 'net present value' economic theory, would be more effective in behavioral intervention than the standard 'future value approach' in reducing cardiovascular morbidity and mortality following angioplasty. At baseline, all patients completed a health assessment, received an individualized risk profile and selected risk factors for modification. The intervention randomized patients into two varying methods for illustrating positive effects of behavior change. For the experimental group, each selected risk factor was assigned a numeric biologic age (the net present value) that approximated the relative potential to improve current health status and quality of life when modifying that risk factor. In the control group, risk reduction was framed as the value of preventing future health problems. Ninety-four percent of patients completed 2-year follow-up. There was no difference between the rates of death, stroke, myocardial infarction, Class II-IV angina or severe ischemia (on non-invasive testing) between the net present value group and the future value group. Our results show that a net present risk communication intervention did not result in significant differences in health outcomes.

An evaluation of post-resuscitation care as a possible explanation of a difference in survival after out-of-hospital cardiac arrest.

BACKGROUND: A recently published study has shown that survival after out-of-hospital cardiac arrest (OHCA) in Göteborg is almost three times higher than in Stockholm. The aim of this study was to investigate whether in-hospital factors were associated with outcome in terms of survival. METHODS: All patients suffering from OHCA in Stockholm and Göteborg between January 1, 2000 and June 30, 2002 were included. The two groups were compared with reference to patient characteristics, medical history, pre-hospital and hospital course (including in-hospital investigations and interventions) and mortality. All medical charts from patients admitted alive to the different hospitals were studied. Data from the Swedish National Register of Deaths regarding long-term survival were analysed. Pre-hospital data were collected from the Swedish Ambulance Cardiac Arrest Register. RESULTS: In all, 1542 OHCA in Stockholm and 546 in Göteborg were registered during the 30-month study period. In Göteborg, 28% (153 patients) were admitted alive to the two major hospitals whereas in Stockholm 16% (253 patients) were admitted alive to the seven major hospitals (p<0.0001). On admission to the emergency rooms, a larger proportion of patients in Stockholm was unconscious (p=0.006), received assisted breathing (p=0.008) and ongoing CPR (p=0.0002). Patient demography, medical history, in-hospital investigations and interventions and in-hospital mortality (78% in Göteborg, 80% in Stockholm) did not differ between the two groups. Various pre-hospital time intervals were significantly longer in Stockholm than in Göteborg. Total survival to discharge after OHCA was 3.3% in Stockholm and 6.1% in Göteborg (p=0.01). CONCLUSION: An almost 2-fold difference in survival after OHCA between Stockholm and Göteborg appears to be associated with pre-hospital factors only (predominantly in form of prolonged intervals in Stockholm), rather than with in-hospital factors or patient characteristics.

Difference in survival after out-of-hospital cardiac arrest between the two largest cities in Sweden: a matter of time?

BACKGROUND: Dramatic differences in survival after out-of-hospital cardiac arrests (OHCA) reported from different geographical locations require analysis. We therefore compared patients with OHCA in the two largest cities in Sweden with regard to various factors at resuscitation and outcome. SETTING: All patients suffering an OHCA in Stockholm and Goteborg between 1 January 2000 and 30 June 2001, in whom cardiopulmonary resuscitation (CPR) was attempted were included in this retrospective analysis. RESULTS: All together, 969 OHCA in Stockholm and 398 in Goteborg were registered during the 18-month study period. There were no differences in terms of age, gender, and percentage of witnessed cases or percentage of patients who had received bystander CPR. However, the percentage of patients with ventricular fibrillation (VF) at arrival of the ambulance crew was 18% in Stockholm versus 31% in Goteborg (P <0.0001). The percentage of patients who were alive 1 month after cardiac arrest was 2.5% in Stockholm versus 6.8% in Goteborg (P=0.0008). Various time intervals such as cardiac arrest to calling for an ambulance, cardiac arrest to the start of CPR and calling for an ambulance to its arrival were all significantly longer in Stockholm than in Goteborg. CONCLUSION: Survival was almost three times higher in Goteborg than in Stockholm amongst patients suffering an OHCA. This is primarily explained by a higher occurrence of VF at the time of arrival of the ambulance crew, which in turn probably is explained by shorter delays in Goteborg. The reason for the difference in time intervals is most likely multifactorial, with a significantly higher ambulance density in Goteborg as one possible explanation.