Early versus Later Rhythm Analysis in Patients with Out-of-Hospital Cardiac Arrest

Background In a departure from the previous strategy of immediate defibrillation, the 2005 resuscitation guidelines from the American Heart Association–International Liaison Committee on Resuscitation suggested that emergency medical service (EMS) personnel could provide 2 minutes of cardiopulmonary resuscitation (CPR) before the first analysis of cardiac rhythm. We compared the strategy of a brief period of CPR with early analysis of rhythm with the strategy of a longer period of CPR with delayed analysis of rhythm. Methods We conducted a cluster-randomized trial involving adults with out-of-hospital cardiac arrest at 10 Resuscitation Outcomes Consortium sites in the United States and Canada. Patients in the early-analysis group were assigned to receive 30 to 60 seconds of EMS-administered CPR and those in the later-analysis group were assigned to receive 180 seconds of CPR, before the initial electrocardiographic analysis. The primary outcome was survival to hospital discharge with satisfactory functional status (a modified Rankin scale score of ≤3, on a scale of 0 to 6, with higher scores indicating greater disability). Results We included 9933 patients, of whom 5290 were assigned to early analysis of cardiac rhythm and 4643 to later analysis. A total of 273 patients (5.9%) in the later-analysis group and 310 patients (5.9%) in the early-analysis group met the criteria for the primary outcome, with a cluster-adjusted difference of −0.2 percentage points (95% confidence interval, −1.1 to 0.7; P=0.59). Analyses of the data with adjustment for confounding factors, as well as subgroup analyses, also showed no survival benefit for either study group. Conclusions Among patients who had an out-of-hospital cardiac arrest, we found no difference in the outcomes with a brief period, as compared with a longer period, of EMS-administered CPR before the first analysis of cardiac rhythm. (Funded by the National Heart, Lung, and Blood Institute and others; ROC PRIMED ClinicalTrials.gov number, NCT00394706.

Injured Older Adults Transported by Emergency Medical Services: One Year Outcomes by POLST Status

Background: Advance care planning documents, including Physician Orders for Life-Sustaining Treatment (POLST), are intended to guide care near end of life, particularly in emergency situations. Yet, research on POLST during emergency care is sparse. Methods: A total of 7,055 injured patients age ≥ 65 years were transported by 8 emergency medical services (EMS) agencies to 23 hospitals in Oregon. We linked multiple data sources to EMS records, including: the Oregon POLST Registry, Medicare claims data, Oregon Trauma Registry, Oregon statewide inpatient data, and Oregon vital statistics records. We describe patient and event characteristics by POLST status at time of 9-1-1 contact, subsequent changes in POLST forms, and mortality to 12 months. Results: Of 7,055 injured older adults, 1,412 (20.0%) had a registered POLST form at the time of 911 contact. Among the 1,412 POLST forms, 390 (27.6%) specified full orders, 585 (41.4%) limited interventions, and 437 (30.9%) comfort measures only. By one year, 2,471 (35%) patients had completed POLST forms. Among the 4 groups (no POLST, POLST-full orders, POLST-limited intervention, POLST-comfort measures), Injury Severity Scores were similar. Mortality differences were present by 30 days (5.0%, 4.6%, 8.0%, and 13.3%, p \u3c 0.01) and were greater by one year (19.5%, 23.9%, 35.4%, and 46.2%, p \u3c 0.01). Conclusions: Among injured older adults transported by ambulance in Oregon, one in 5 had an active POLST form at the time of 9-1-1 contact, the prevalence of which increased over the following year. Mortality differences by POLST status were evident at 30 days and large by one year. This information could help emergency, trauma, surgical, inpatient, and outpatient clinicians understand how to guide patients through acute injury episodes of care and post-injury follow up