One-year survival after prehospital cardiac arrest: the Utstein style applied to a rural-suburban system.

To evaluate the recently published Utstein algorithm (Ann Emerg Med 1991;20:861), the authors conducted a retrospective review of all advanced life support (ALS) trip sheets and hospital records of patients with prehospital cardiac arrests between January 1988 and December 1989. Telephone follow-up was used to determine 1-year survival rates. Of 713 arrests in the 24-month study period, 601 were of presumed cardiac etiology. Approximately 599 of these charts were available for analysis. One hundred ninety-three (32.2%) of these had return of spontaneous circulation (ROSC), 36 (6.0%) survived to hospital discharge, and 24 were alive at 1-year follow-up (4.0% of total or 67% of survivors to discharge). The Utstein style was found to be a useful algorithmic format for reporting prehospital cardiac arrest data in a manner that should allow direct comparison between emergency medical service (EMS) systems. Existing prehospital record-keeping practices (trip sheets) are easily adapted to this style of data collection, although certain data for the template (eg, resuscitations not attempted and alive at 1-year) are more difficult to ascertain. Additionally, the authors report their own experience during a 2-year period, including data that suggest that the majority of patients with cardiac arrest who survive to hospital discharge are still alive at 1 year.

Intraosseous infusion: success of a standardized regional training program for prehospital advanced life support providers.

STUDY OBJECTIVE: To evaluate a standardized training program in intraosseous (IO) infusion for prehospital providers. DESIGN: Prospective multicenter 24-month study. SETTING: IO infusions were performed by prehospital providers from eight advanced life support units serving 14 hospitals within nine counties. PARTICIPANTS: Field advanced life support providers (paramedics and registered nurses). INTERVENTIONS: All providers participated in a one-hour standardized training session and supervised hands-on simulation. Providers completed a data sheet on all IO infusions performed. Data sheets were collected and summarized. RESULTS: One hundred thirty-four prehospital providers completed the training session and were approved to perform the procedure. Fifteen patients requiring IO infusion were encountered during the study period. Thirteen (87%) had IO infusion completed successfully. Clinical indications included 11 patients in cardiac arrest, two trauma resuscitations, one seizure, and one toxic ingestion. Patient ages ranged from 1 to 24 months. Seven patients were initially resuscitated. Four survived to hospital discharge. Procedural complications included one incidence of local fluid extravasation and one IO line that became dislodged en route. There were no complications at time of discharge in the four survivors. All procedures were performed in less than two minutes. CONCLUSION: A one-hour standardized training session was successfully used to train prehospital providers in the procedure of IO infusion. IO infusion then was implemented into their clinical practice with a satisfactory success rate and few complications.

Early defibrillation program: problems encountered in a rural/suburban EMS system.

Many studies have shown improved survival of cardiac arrest patients by the use of early defibrillation (EMT-D) in the field. This prospective study was the first in Pennsylvania and was undertaken to determine if an EMT-D program would be successful in our suburban/rural setting. One hundred two EMTs were trained to use a semi-automatic defibrillator and data were collected over 16 months. There were 96 cardiac arrests, with only 33 patients (34%) presenting with initially treatable dysrhythmias--ventricular fibrillation (VF) or tachycardia (VT). Twenty-three patients (24%) were admitted to the hospital; survival to hospital discharge occurred in only 5 patients (5.2%). Survival to hospital admission was higher among VF/VT presenting rhythms (36%) than for those with other rhythms (17%, P = 0.07), but survival to discharge among VF/VT rhythms (9%) was not statistically different from other rhythms (3%, P = 0.45). Among VF/VT patients, survival to discharge was correlated with shorter call to first defibrillation intervals. Mean call to response interval was longer than in other reported studies (7.2 +/- 4.3 minutes). In addition, there was a high drop-out rate of EMT participants, no central/uniform early access system (that is, 911), and a lower rate of CPR than reported in other studies. It is concluded that introduction of an EMT-D program without careful analysis of systems response factors will not lead to the improved cardiac arrest survival percentages that have previously been reported.

An evaluation of automated defibrillation and manual defibrillation by emergency medical technicians in a rural setting.

We show that automated external defibrillation training of emergency medical technicians (EMTs) is less time consuming than manual defibrillation training, and hypothesize that both improve survival from sudden cardiac death. Data on 91 cardiac arrests over 27 months among five basic life support services was collected before EMT-defibrillation (EMT-D) training. Subsequently, seven BLS services were trained in EMT-D using either manual difibrillation or automated external defibrillation technology, and 55 sudden cardiac death patients were entered after training. Manual defibrillation required 11 more hours per student in initial training. Survival to hospital discharge improved from two of 91 patients (2.2%) in the series before EMT-D training to nine of 55 patients (16.4%) after EMT-D training (P = .001). Improved survival was correlated with shorter prehospital defibrillation times, 8.84 minutes, when EMTs performed defibrillation versus 16.3 minutes before training when EMTs awaited advanced life support defibrillation (P < .001). To enhance equipment familiarity we allowed EMTs to apply three-lead electrode monitors to all medical/cardiac patients during transport (surveillance). There were six emergency medical service-witnessed "surveillance" arrests and three arrests survived to hospital discharge (50% survival). This group represented 33% of all survivors in the series. We recommend automated external defibrillation training for EMTs. Improved survival in sudden cardiac death cases in well-run emergency medical service systems should result from EMT-D training. Finally, we recommend that routine "surveillance" of high-risk patients during transport by defibrillation-capable EMTs be considered in EMT-D programs, rather than limiting EMT-D only to units capable of rapid "man-down" response.