Clinical rules have been developed to identify acute trauma patients who require imaging of the cervical spine. While the computed tomography (CT) scan is highly sensitive for detecting cervical spine injury (CSI), unnecessary ionizing radiation is of concern, especially in children. The clinical rules have been more extensively tested in adults; however, there is support in the literature for National Emergency X-Radiography Utilization Study criteria (NEXUS) to reliably detect injury in children over 7 years old.

Introduction: The 2010 American Heart Association Guidelines stated that “cardiopulmonary resuscitation prompt and feedback devices may be useful for training rescuers and may be useful as part of an overall strategy to improve the quality of CPR for actual cardiac arrests.” We sought to assess the effect of one such device on OOHCA outcomes in a large, urban setting. Methodology: Out-of-hospital cardiac arrest data from two consecutive twelve-month periods was analyzed: August 1, 2010 - July 31, 2011 (control) and August 1, 2011 - July 31, 2012 (CPR feedback). During the CPR feedback period, defibrillators capable of providing real-time audible and visual CPR feedback were added to standard prehospital resuscitation care. Results: There were 850 and 748 bystander witnessed arrests of cardiac etiology in the two periods. Patient and arrest characteristics for the two groups did not differ with respect to age, gender, race, response time, bystander witnessed status, or the frequency of bystander CPR. As compared to the control period, the addition of real-time CPR feedback resulted in a significant improvement in immediate outcomes: return of spontaneous circulation, or ROSC (39.59% vs. 47.71%, p=0.001); sustained ROSC (31.17% vs. 36.14%, p= 0.037). However, there was no improvement in survival to hospital admission (24.88% vs. 25.32%, p=0.85) or survival to hospital discharge (5.63% vs. 6.72%, p=0.43). In addition, among those survivors for whom neurologic status is known, the addition of CPR feedback did not significantly change the proportion of survivors considered neurologically intact (70.37% vs 65.63%, all p=0.78). Conclusions: The addition of real-time CPR feedback to a large urban EMS system’s resuscitation care resulted in significant improvements in immediate survival but did not affect overall survival rates. It is also possible earlier introduction of these devices (through their use by first responder and/or earlier arriving basic life support units) may provide greater benefit. Further data analysis is required to determine the specific effect of CPR feedback devices on long-term survival and to optimize their use in resuscitation care.

Introduction: In 2005, the Prehospital Evaluation of New York City Survival (PHENYCS) study modest improvements in out-of-hospital cardiac arrest survival as a result of the merger of New York City EMS and the Fire Department of New York. Since that time, numerous changes have been implemented with the intent of further improving survival (e.g. compressions only pre-arrival instructions, ventricular fibrillation waveform analysis in automated defibrillators, emphasis on basic resuscitation, de-emphasis of advanced resuscitation, waveform capnography, resuscitation team leaders, integration of therapeutic hypothermia as a post-resuscitation care standard). We sought to assess the effects of these changes and to describe the current OOHCA survival rates for this large urban system. Methods: We analyzed data from a three-year period (August 1, 2009 - July 31, 2012) and for the purposes of presenting rhythm determination was limited to those OOHCA cases for which paramedics were the first arriving EMS unit. Results: 717 bystander witnessed OOHCA cases of cardiac etiology were followed to hospital discharge. The presenting rhythm were ventricular fibrillation (VF) / ventricular tachycardia (VT) in 19.4%, pulseless electrical activity (PEA) in 24.1%, asystole in 51.6% and other rhythms in 4.9%. As compared to the PHENYCS study, this is a significant reduction the incidence of VF/VT (19.4% vs 24.7%, p=0.005). As compared to the PHENYCS study, there were significant improvements in all survival endpoints: ROSC (38.5% vs 20.2%, p Conclusions: This most recent analysis of OOHCA outcomes for New York City finds that despite a continuing decline in the incidence of VF/VT as the presenting rhythm, there has been a doubling of survival at all endpoints and for all rhythms. Further work is needed to elucidate the causes of this improvement and to further focus OOHCA care on those interventions that are most likely to contribute to survival.

Introduction: The infusion of ice-cold saline (ICS) is often employed for the initiation of therapeutic hypothermia, and many protocols suggest an infusion of up to 30cc/kg in order to achieve one commonly used target temperature range of 32-34 degrees Celcius. We sought to determine if there was any association between ICS volume and core temperature reduction. Methods: We analyzed a convenience sample of out-of-hospital cardiac arrest patients for whom therapeutic hypothermia was being inducted via pressurized ICS infusion and for whom core body temperature was being monitored via an esophageal temperature probe. Results: Esophageal core temperature data was available for 287 patients. The average patient received 1,136ml (SD 472mL) of ICS via pressure infusion. The average core body temperature upon ED arrival was within the identified target range for all patients (33.2oC, SD 2.3 oC). Among patients who received 1500ml (n=48), average core body temperature achieved target range for all groups (33.34 oC, 33.25 oC, 33.5 oC and 32.87 oC, respectively) though there were patients in each group whose core body temperature was either above or below the target range (SD = 2.64 oC, 2.26 oC, 1.34 oC and 2.11 oC, respectively). No correlation was found between the reduction in core body temperature and the infused volume of ICS (ΔT = -0.95 oC±1.52, -1.51 oC ±1.93, -1.40 oC±1.38, -1.45 oC±1.21, respectively). Conclusions: Though perhaps tempered by the disproportionate number of patients in one group, our data would suggest that the relative reduction in and resulting final core body temperature are not a function of the infused volume for patient undergoing the induction of therapeutic hypothermia via ICS infusion. Therefore, if targeted temperature therapy is of clinically important, continuous core temperature monitoring during the induction of cooling is essential to ensure target acquisition.

Introduction: The resuscitation literature has recently suggested that the prehospital initiation of therapeutic hypothermia following successful resuscitation does not alter outcomes among patients who suffer sudden out-of-hospital cardiac arrest (OOHCA). We sought to assess the impact of earlier, intra-arrest induction of therapeutic hypothermia on OOHCA survival. Methodology: Out-of-hospital cardiac arrest data from two consecutive twelve-month periods was analyzed: August 1, 2009 - July 31, 2010 (Phase I), August 1, 2010 - July 31, 2011 (Phase II). In Phase I, paramedics in this urban system transported OOHCA patient to participating Cardiac Arrest Centers where the use of therapeutic hypothermia had been incorporated to the standard post-resuscitation care pathway. In Phase II, paramedics initiated hypothermia during the initial resuscitation effort through the rapid infusion of large-volume, ice-cold saline. Consistent with the Utstein definitions, analyses utilized only those cases which were bystander witnessed and of cardiac etiology. Results: There were 1,487 and 850 bystander witnessed arrests of cardiac etiology in the two phases. Patient and arrest characteristics for the two groups did not differ with respect to age, gender, race, response time, bystander witnessed status, or the frequency of bystander CPR. Return of spontaneous circulation (ROSC), sustained ROSC, survival to hospital admission and survival to hospital discharge did not differ significantly from Phase I to Phase II: 40.82% vs 39.59% (p=.54), 31.10% vs 31.17% (p=0.58), 27.15% vs 24.88% (p=0.27), and 6.62% vs 6.19% (p=0.41). In addition, among those survivors for whom neurologic status is known, the intra-arrest initiation of therapeutic hypothermia did not significantly change the proportion of survivors considered neurologically intact (76.47% vs 70.37%, all p=0.59). Conclusions: The intra-arrest initiation of therapeutic hypothermia did not alter outcomes among OOHCA patients, demonstrating neither harm nor benefit. Whether this is due to a lack of continuation of hypothermia following hospital admission or a true lack of benefit requires further collaborative work between the prehospital and hospital communities.

Study ObjectiveCardiac tamponade is a potentially life-threatening clinical process that may be difficult to recognize in the acute care setting since the typically described textbook presentation is uncommon. For example, hypotension is often absent at the time of the diagnosis, and in fact hypertension is a common finding (Kapoor et al J of Emer Med May 2010). While low voltage on an EKG should raise suspicion for the presence of pericardial effusion and tamponade, numerous reports indicate a relatively low sensitivity and specificity of this finding. We speculated that a change in the EKG voltage might improve diagnosis and our goal was to determine whether comparison of an emergency department (ED) EKG to an EKG obtained in a prior visit helps in identifying cardiac tamponade in patients presenting to the ED.MethodsWe conducted a retrospective chart review from a five-year time period identifying cases by hospital discharge ICD codes. Eligible cases included the diagnosis of tamponade, a pericardial effusion, and an EKG on ED presentation. Tamponade was diagnosed either by ECHO or deemed present at surgery. Low EKG voltage was defined using the criteria of <5mm voltage in each standard limb lead and <10mm in each precordial lead (Chou's Electrocardiography in Clinical Practice: Adult and Pediatric, 6e 2008). A change in voltage was calculated as follows: for each patient the limb and chest leads were added separately on both the baseline and study EKGs. From these figures, the average change in limb and chest lead voltages was calculated. The study was approved by the Human Investigational Review Board.ResultsOf the 32 patients included in the study, a total of 3 (10%) had low voltage on the ED EKG. Among the 32 patients, 15 had a prior EKG done at our institution which was available for review. All 15 patients had a decrease in voltage in either one or both leads. In 12 patients there was a voltage decrease in both limb and chest leads, with an average decrease of 3.0mm in the limb leads and 6.0mm in the chest leads. Furthermore, in 8 patients, the average drop in voltage in at least one of the two lead groupings was more substantial and exceeded 5mm or 1 large box on the EKG. Of note, most (6/8) of these patients did not have low voltage on the ED tamponade EKG.ConclusionsLow voltage on the EKG infrequently occurs in ED diagnosed cardiac tamponade and should not be used to exclude the diagnosis. Since decreases in EKG voltages were commonly found in patients with tamponade, this may represent a better way to utilize the EKG in diagnosing tamponade. A larger study is needed to develop EKG criteria that may assist for tamponade screening. Study ObjectiveCardiac tamponade is a potentially life-threatening clinical process that may be difficult to recognize in the acute care setting since the typically described textbook presentation is uncommon. For example, hypotension is often absent at the time of the diagnosis, and in fact hypertension is a common finding (Kapoor et al J of Emer Med May 2010). While low voltage on an EKG should raise suspicion for the presence of pericardial effusion and tamponade, numerous reports indicate a relatively low sensitivity and specificity of this finding. We speculated that a change in the EKG voltage might improve diagnosis and our goal was to determine whether comparison of an emergency department (ED) EKG to an EKG obtained in a prior visit helps in identifying cardiac tamponade in patients presenting to the ED. Cardiac tamponade is a potentially life-threatening clinical process that may be difficult to recognize in the acute care setting since the typically described textbook presentation is uncommon. For example, hypotension is often absent at the time of the diagnosis, and in fact hypertension is a common finding (Kapoor et al J of Emer Med May 2010). While low voltage on an EKG should raise suspicion for the presence of pericardial effusion and tamponade, numerous reports indicate a relatively low sensitivity and specificity of this finding. We speculated that a change in the EKG voltage might improve diagnosis and our goal was to determine whether comparison of an emergency department (ED) EKG to an EKG obtained in a prior visit helps in identifying cardiac tamponade in patients presenting to the ED. MethodsWe conducted a retrospective chart review from a five-year time period identifying cases by hospital discharge ICD codes. Eligible cases included the diagnosis of tamponade, a pericardial effusion, and an EKG on ED presentation. Tamponade was diagnosed either by ECHO or deemed present at surgery. Low EKG voltage was defined using the criteria of <5mm voltage in each standard limb lead and <10mm in each precordial lead (Chou's Electrocardiography in Clinical Practice: Adult and Pediatric, 6e 2008). A change in voltage was calculated as follows: for each patient the limb and chest leads were added separately on both the baseline and study EKGs. From these figures, the average change in limb and chest lead voltages was calculated. The study was approved by the Human Investigational Review Board. We conducted a retrospective chart review from a five-year time period identifying cases by hospital discharge ICD codes. Eligible cases included the diagnosis of tamponade, a pericardial effusion, and an EKG on ED presentation. Tamponade was diagnosed either by ECHO or deemed present at surgery. Low EKG voltage was defined using the criteria of <5mm voltage in each standard limb lead and <10mm in each precordial lead (Chou's Electrocardiography in Clinical Practice: Adult and Pediatric, 6e 2008). A change in voltage was calculated as follows: for each patient the limb and chest leads were added separately on both the baseline and study EKGs. From these figures, the average change in limb and chest lead voltages was calculated. The study was approved by the Human Investigational Review Board. ResultsOf the 32 patients included in the study, a total of 3 (10%) had low voltage on the ED EKG. Among the 32 patients, 15 had a prior EKG done at our institution which was available for review. All 15 patients had a decrease in voltage in either one or both leads. In 12 patients there was a voltage decrease in both limb and chest leads, with an average decrease of 3.0mm in the limb leads and 6.0mm in the chest leads. Furthermore, in 8 patients, the average drop in voltage in at least one of the two lead groupings was more substantial and exceeded 5mm or 1 large box on the EKG. Of note, most (6/8) of these patients did not have low voltage on the ED tamponade EKG. Of the 32 patients included in the study, a total of 3 (10%) had low voltage on the ED EKG. Among the 32 patients, 15 had a prior EKG done at our institution which was available for review. All 15 patients had a decrease in voltage in either one or both leads. In 12 patients there was a voltage decrease in both limb and chest leads, with an average decrease of 3.0mm in the limb leads and 6.0mm in the chest leads. Furthermore, in 8 patients, the average drop in voltage in at least one of the two lead groupings was more substantial and exceeded 5mm or 1 large box on the EKG. Of note, most (6/8) of these patients did not have low voltage on the ED tamponade EKG. ConclusionsLow voltage on the EKG infrequently occurs in ED diagnosed cardiac tamponade and should not be used to exclude the diagnosis. Since decreases in EKG voltages were commonly found in patients with tamponade, this may represent a better way to utilize the EKG in diagnosing tamponade. A larger study is needed to develop EKG criteria that may assist for tamponade screening. Low voltage on the EKG infrequently occurs in ED diagnosed cardiac tamponade and should not be used to exclude the diagnosis. Since decreases in EKG voltages were commonly found in patients with tamponade, this may represent a better way to utilize the EKG in diagnosing tamponade. A larger study is needed to develop EKG criteria that may assist for tamponade screening.

Current guidelines recommend that patients with chest pain and electrocardiogram (ECG) findings consistent with an ST-segment elevation myocardial infarction (STEMI) or new-onset left bundle branch block (LBBB) receive fibrinolytics within 30 min of arrival or percutaneous coronary intervention (PCI) within 90 min of arrival. New York City Emergency Medical Service has guidelines for potential STEMI patients to be transported to designated cardiac catheterization (CC) centers. In our hospital, a total of 51% of these patients go for CC, roughly 29% emergently and 23% after admission. We sought to determine the ECG findings on those patients that never went for CC.

Relationships between aggregate volumes of Emergency Medical Services (EMS) utilization and socioeconomic status (SES) have been previously described, most often demonstrating an inverse relationship between the 2. Epidemiologic research from emergency department or hospital records have demonstrated increased prevalence of certain medical conditions in low-income populations. In this study, we sought to describe the relationship between SES and utilization of EMS in New York City (NYC) across a spectrum of specific medical concerns, and determine if there are differences in the patterns of utilization across different SES groups. This retrospective cohort study was performed using data from the electronic Patient Care Report database from the Fire Department of the City of New York (FDNY), the municipal provider of EMS for NYC, accounting for approximately 64% of 911 EMS responses. The FDNY patient care report database was queried for all patient contacts between November, 2005 and December, 2009. The patient's medical concerns, as well as home zip code, were extracted. Each unique patient encounter was assigned an income value as a proxy for SES by correlating the patient's home zip code to published United States Census Bureau median income data for 2008. Patients were then divided into deciles according to the assigned income. Using this method, the relative frequency of each medical concern in each decile was tabulated. Statistical correlations between the relative frequency of each medical concern and income decile were measured using Spearman's rank coefficients. Individual medical concerns were categorized as either medical/surgical or trauma related and similarly correlated to income decile. All data analysis was performed using the Statistical Package for the Social Sciences (SPSS) v18. A total of 2,402,675 unique subject encounters were analyzed. Statistically significant negative correlations (lower SES associated with higher EMS utilization) were identified for the principal concerns of fever (-0.988), sore throat (-0.988), abdominal pain (-0.976), asthma (-0.927) and stabbings (-0.782) [all p<0.01]. Statistically significant positive correlations (higher SES associated with higher EMS utilization) were found for the principal concerns of syncope (0.988), motor vehicle accidents (0.988), falls (0.976), and respiratory arrest (0.939) [all p<0.001]. No significant trends were seen for assaults, gastrointestinal bleeds, chest pain, or allergic reactions. Overall, there was a positive correlation for all combined trauma related concerns (0.939, p<0.001) and a negative correlation for all combined medical/surgical concerns (-0.927, p<0.001). Using income level as a surrogate for SES, our study demonstrates very strong relationships between SES and EMS utilization among specific medical concerns. While aggregate volumes of EMS calls are known to be higher among low SES populations, not all types of medical concerns rise uniformly. The distribution of medical concerns varies considerably at different income levels, with lower income levels tending to utilize EMS in greater proportions for chronic conditions such as asthma. This out-of-hospital data supports findings from hospital studies demonstrating the need for increased primary and preventative care in low-income communities.

To determine the EKG findings on those patients arriving as EMS STEMI notification who never went for cardiac catheterization. National organizational guidelines recommend that patients with chest pain and EKG findings consistent with a ST segment elevation myocardial infarction (STEMI) (or new onset LBBB) receive fibrinolytics within 30 minutes of emergency department arrival or percutaneous coronary intervention within 90 minutes of arrival. In 2007 the New York City Emergency Medical Service (NYC EMS) developed guidelines for out-of-hospital providers along with physician-guided telemetry to identify potential STEMI patients, and transport them to designated 24 hour cardiac catheterization centers. In our hospital a total of 51% of these patients go for cardiac catheterization, roughly 29% emergently and another 23% after admission to the hospital. Retrospective chart review of all 205 STEMI notifications presenting to an academic emergency department (ED) between 11/27/07 and 7/4/10. The initial EKGs were analyzed independently by 2 board certified emergency physicians and 1 board certified cardiologist who were blinded to the presenting complaint and outcome of the patient. When there was disagreement with regards to the interpretation the consensus 2 of the 3 reviewers was used as the final diagnosis. The average age for the 205 patients was 65 years (range 28-97) and 122 (60%) were male. A total of 100/205 (49%) patients never went for cardiac catheterization, with 95/100 not having an initial EKG consistent with STEMI . Of the remaining 5 patients with a STEMI EKG who did not have a cardiac catheterization 1 died shortly after arrival to the ED, 3 did not go for catheterization because of advanced age, co-morbidities and or family wishes, and the last patient had negative cardiac markers. Based on study review, the most common EKG findings in the 95 non-STEMI patients was a LBBB which was seen in 33/95(35%) of cases. Other EKG findings included age-indeterminate MIs (21%); left ventricular hypertrophy with repolarization abnormalities (17%); normal EKG or J point elevation (11%); and either non specific ST changes or T wave inversion (12%). In addition 5% had a paced rhythm and 3% had complete heart block further making the diagnosis of STEMI challenging. About half of STEMI notifications presenting to an ED did not have a cardiac catheterization during the hospitalization. These patients almost always had other EKG abnormalities or a LBBB that obscured the identification of STEMI. Assuming LBBB transport guidelines are not revised, further decreases in non-STEMI transports to a cardiac catheterization center would be difficult in the out-of-hospital setting.

Purpose: The 2005 American Heart Association Guidelines noted the potential use of ventricular fibrillation (VF) waveform analysis to "include prediction of success of cardioversion… and optimization of timing of defibrillation relative to CPR and medication delivery."1 This prospective double-blinded randomized controlled trial was designed to assess the use of a VF waveform analysis algorithm to improve survival.Methods: Out-of-hospital cardiac arrest (OOHCA) patients from two large metropolitan EMS systems were treated with automated external defibrillators (AEDs) randomized to a universal shock-first or VF waveform analysis protocol. Study inclusion was limited to presenting VF of primary cardiac aetiology. VF waveform characteristics were used to calculate a novel score representing VF quality. Patients whose score was below a predefined threshold received either immediate defibrillation or a 2-min period of CPR prior to defibrillation based on AED randomization. The primary outcome was survival to hospital discharge.Results: Between May 5, 2006 and June 30, 2009, a total of 6738 OOHCA patients were enrolled. 5751 patients were excluded, the majority (85%) due to a non-VF presenting rhythm. Of the 987 included cases, 540 (54.7%) presented below threshold and comprised the primary analysis group. Based on the AED randomization, 262/540 patients were given two minutes of CPR prior to defibrillation and 278/540 patients were treated with a shock-first protocol. The initial VF score was highly predictive (p < 0.001) for survival to hospital discharge overall. For subjects below threshold, no significant differences were identified between the shock-first and CPR-first protocols for ROSC (27% vs. 29%, p = 0.57), sustained ROSC (20% vs. 22%, p = 0.75), and survival to admission (23% vs. 22%, p = 1.00) or discharge (7% vs. 7%, p = 1.00).Conclusions: Initial VF score is highly predictive for subsequent survival to hospital discharge. However, its use to guide initial CPR treatment for patients with low quality VF did not alter survival. Purpose: The 2005 American Heart Association Guidelines noted the potential use of ventricular fibrillation (VF) waveform analysis to "include prediction of success of cardioversion… and optimization of timing of defibrillation relative to CPR and medication delivery."1 This prospective double-blinded randomized controlled trial was designed to assess the use of a VF waveform analysis algorithm to improve survival. Methods: Out-of-hospital cardiac arrest (OOHCA) patients from two large metropolitan EMS systems were treated with automated external defibrillators (AEDs) randomized to a universal shock-first or VF waveform analysis protocol. Study inclusion was limited to presenting VF of primary cardiac aetiology. VF waveform characteristics were used to calculate a novel score representing VF quality. Patients whose score was below a predefined threshold received either immediate defibrillation or a 2-min period of CPR prior to defibrillation based on AED randomization. The primary outcome was survival to hospital discharge. Results: Between May 5, 2006 and June 30, 2009, a total of 6738 OOHCA patients were enrolled. 5751 patients were excluded, the majority (85%) due to a non-VF presenting rhythm. Of the 987 included cases, 540 (54.7%) presented below threshold and comprised the primary analysis group. Based on the AED randomization, 262/540 patients were given two minutes of CPR prior to defibrillation and 278/540 patients were treated with a shock-first protocol. The initial VF score was highly predictive (p < 0.001) for survival to hospital discharge overall. For subjects below threshold, no significant differences were identified between the shock-first and CPR-first protocols for ROSC (27% vs. 29%, p = 0.57), sustained ROSC (20% vs. 22%, p = 0.75), and survival to admission (23% vs. 22%, p = 1.00) or discharge (7% vs. 7%, p = 1.00). Conclusions: Initial VF score is highly predictive for subsequent survival to hospital discharge. However, its use to guide initial CPR treatment for patients with low quality VF did not alter survival.

Purpose: Significant variation has been described among Emergency Medical Services (EMS) systems throughout the world with respect to out-of-hospital cardiac arrest (OOHCA). We sought to describe such variation among two of the world's busiest EMS systems, each responding to over one million calls annually.1–3 Methods: Data collected as part of a large randomized controlled out-of-hospital resuscitation trial in New York City (NYC) and London were analyzed. Enrollment began in London on May 5, 2006 and in NYC on May 13, 2007. Both sites concluded enrolment on June 30, 2009. Results: A total of 6738 OOHCA cases were enrolled. Ventricular fibrillation (VF) was less likely to be the presenting rhythm among patients in NYC (16.1% vs 22.3%, p < 0.0001), though the annual incidence of VF was higher in that system (3.46 vs 2.16 per 100,000). Among patients presenting with bradyasystolic rhythms, survival was better in London though poor in both cities (1.89% vs 1.01%, p = .02). VF patients in NYC were typically younger (median age 62 years vs 70 years), less likely to have received bystander CPR (24.4% vs 46.9%, p < 0.0001), and experienced shorter EMS response time (median = 3 min, 38 s vs 5 min, 24 s). No differences were noted in return of spontaneous circulation (42.5% vs 41.2%, p = .70), though VF patients in NYC were more likely to be declared deceased in the field (8.9% vs 2.0%, p < .0001). There were no differences in survival to admission (33.5% vs 38.2%, p = .12) or survival to discharge (15.5% vs 17.8%, p = .34). Among the subgroup of EMS-witnessed VF cardiac arrest patients (n = 52), there was also no difference in survival to admission (50.0% vs 56.7%, p = .78) or discharge (31.8% vs 40.0%, p = .58). Conclusions: Despite differences in the characteristics of OOHCA in New York and London, the overall survival rates were remarkably similar between the two cities.

Purpose: We compared characteristics of the ventricular fibrillation (VF) waveform and Emergency Medical Service (EMS) response time in their ability to predict patient outcomes from out-of-hospital cardiac arrest (OOHCA). Although some studies have shown EMS response time to be a strong predictor of patient outcome, it is difficult to measure and may not accurately reflect patient down-time.1–4 Methods: ECG data collected during a large multi-center study involving 987 out-of-hospital cardiac arrests with patients presenting in VF was analyzed. The ECG was recorded on Philips Healthcare FR2 automatic external defibrillators (AEDs) and a 5 s segment of the initial recorded rhythm was analyzed using a proprietary algorithm to calculate a VF score. EMS response time was measured from call to ambulance arrival on scene. Using logistic regression, the predictive ability of the VF waveform score and EMS response time was assessed for the following outcomes: return of spontaneous circulation (ROSC), sustained-ROSC, hospital admission and discharged alive from hospital. Results: Odds ratios [95% confidence limits] for the VF score and EMS response time respectively, ROSC: 3.84 (2.98–4.95) p < 0.0001, vs. 0.96 (0.91–1.01) p = 0.12; S-ROSC: 3.95 (3.02–5.17) p < 0.0001 vs. 0.98 (0.93–1.04) p = 0.51; admission: 4.04 (3.10–5.27) p < 0.0001 vs. 0.99 (0.93–1.05) p = 0.66; discharge: 5.15 (3.65–7.31) p < 0.0001 vs. 0.98 (0.92–1.05) p = 0.61. The Pearson correlation coefficient between VF score and EMS response time was −0.05 (p = 0.12). Conclusions: Using the presenting VF rhythm, we were able to calculate a score which was highly predictive of patient outcomes. EMS response time was not a strong predictor. This VF waveform analysis may be used to direct resuscitations by identifying patients who are likely to respond well to standard treatment with positive outcomes and those patients who may benefit from alternative procedures.

Purpose: This study examined the impact of three critical environmental and societal factors on the initial ECG waveform and eventual patient outcomes: bystander witness, bystander CPR and EMS witness using a VF score. This score predicts survival outcomes in out-of-hospital-cardiac arrest (OOHCA) patients better than traditional predictors such as response times.1Russell J.K. White R.D. Crone W.E. Analysis of the ventricular fibrillation waveform in refibrillation.Crit Care Med. 2006; 34: S432-S437Crossref PubMed Scopus (5) Google ScholarMethods: ECG data was collected during a multi-center, randomized controlled trial on OOHCA patients presenting in VF. Waveform characteristics were used to calculate a novel score representing VF quality using a Philips Healthcare AED algorithm.Results: Cardiac arrests were witnessed by EMS in 5.3% (52/980) of the study population. In 77% (755/980) of the cases, the cardiac arrest was bystander witnessed. Bystander CPR was provided in 38.4% of these cases. The median score of the presenting VF in EMS witnessed arrests was 71% higher than that of non-witnessed arrests with a corresponding improvement in survival of 27.2%. When compared to VF scores of patients who had a bystander witnessed cardiac arrest, the EMS witnessed VF score was 46% higher with a corresponding improvement in survival of 19.6%. Similarly, the effect of bystander witness alone versus not witnessed resulted in a 17% higher VF score with a 7.6% increase in survival. These three gains in VF score and survival were significant (p < 0.0001, Kruskal–Wallis). Bystander CPR, resulted in a VF score gain of 26.3% (Wilcoxan p < 0.0001) and a corresponding significant increase in survival of 11.4% when compared with cardiac arrests that were bystander witnessed but received no bystander CPR.Conclusions: Presenting VF scores and corresponding survival rates are significantly higher for patients who have a witnessed cardiac arrest and received bystander CPR. Thus the VF score is not only reflective of the VF quality but also inherently related to treatability and highly predictive of survival and thereby could be used to guide protocols. Purpose: This study examined the impact of three critical environmental and societal factors on the initial ECG waveform and eventual patient outcomes: bystander witness, bystander CPR and EMS witness using a VF score. This score predicts survival outcomes in out-of-hospital-cardiac arrest (OOHCA) patients better than traditional predictors such as response times.1Russell J.K. White R.D. Crone W.E. Analysis of the ventricular fibrillation waveform in refibrillation.Crit Care Med. 2006; 34: S432-S437Crossref PubMed Scopus (5) Google Scholar Methods: ECG data was collected during a multi-center, randomized controlled trial on OOHCA patients presenting in VF. Waveform characteristics were used to calculate a novel score representing VF quality using a Philips Healthcare AED algorithm. Results: Cardiac arrests were witnessed by EMS in 5.3% (52/980) of the study population. In 77% (755/980) of the cases, the cardiac arrest was bystander witnessed. Bystander CPR was provided in 38.4% of these cases. The median score of the presenting VF in EMS witnessed arrests was 71% higher than that of non-witnessed arrests with a corresponding improvement in survival of 27.2%. When compared to VF scores of patients who had a bystander witnessed cardiac arrest, the EMS witnessed VF score was 46% higher with a corresponding improvement in survival of 19.6%. Similarly, the effect of bystander witness alone versus not witnessed resulted in a 17% higher VF score with a 7.6% increase in survival. These three gains in VF score and survival were significant (p < 0.0001, Kruskal–Wallis). Bystander CPR, resulted in a VF score gain of 26.3% (Wilcoxan p < 0.0001) and a corresponding significant increase in survival of 11.4% when compared with cardiac arrests that were bystander witnessed but received no bystander CPR. Conclusions: Presenting VF scores and corresponding survival rates are significantly higher for patients who have a witnessed cardiac arrest and received bystander CPR. Thus the VF score is not only reflective of the VF quality but also inherently related to treatability and highly predictive of survival and thereby could be used to guide protocols.

Introduction: The 2005 American Heart Association Guidelines recommend defibrillation "as soon as possible" for emergency medical service (EMS)-witnessed out-of-hospital cardiac arrest (OOHCA).1 In such cases, ventricular fibrillation (VF) will likely have little time to deplete myocardial substrates or experience significant wavebreak, making it amenable to immediate defibrillation. We sought to describe the initial characteristics of VF waveforms for EMS-witnessed arrests and to relate these to patient outcome. Methods: Data collected as part of an international prehospital resuscitation trial involving OOHCA presenting in VF of primary cardiac etiology was analyzed. Waveform characteristics were used to calculate a score representing VF quality for all patients. The predictive value of the VF score for survival outcomes was assessed. EMS witnessed cardiac arrests were compared to non-EMS witnessed cases with respect to VF scores and patient outcome. Results: For all out-of-hospital-cardiac-arrests (n = 985), the VF score was highly predictive for all patient outcomes (max p < 0.02). EMS providers witnessed 52/985 (5.3%) cardiac arrests. The median normalized VF score for these patients was 0.144 (range 0.026–1.000). This was significantly higher than the median score for patients whose arrests were not witnessed by EMS providers (0.096, range 0.019–0.562, p = 0.0001). Outcomes were better among EMS witnessed cardiac arrests: return of spontaneous circulation (ROSC) (62% vs 41%, p = .004), sustained ROSC (55% vs 33%, p = .002), survival to hospital admission (54% vs 35%, p = .007), and survival to hospital discharge (37% vs 15%, p = .0003). Conclusion: Though VF quality was higher among EMS-witnessed cardiac arrests, there was a surprising range among initial VF scores in this population and overlap with those arrests not witnessed by EMS, representing a wide array of waveform morphology for new-onset VF. Given the correlation between outcome and VF scores in this population, waveform analysis for outcome prediction and potential therapeutic guidance may be useful.

Purpose: Out-of-hospital cardiac arrest patients who do not respond to resuscitation efforts in the field rarely survive to hospital admission or discharge. In fact, termination of resuscitation rules suggest these patients should not be transported to hospital. We sought to determine the characteristics of the small group who survive to hospital admission despite unsuccessful pre-hospital resuscitation. Methods: Data collected from 985 ventricular fibrillation (VF) pre-hospital cardiac arrests of cardiac aetiology, as part of a large multi-site randomised controlled trial, were analysed. Comparisons were made between those successfully resuscitated in the field (achieved return of spontaneous circulation (ROSC)) and those not. Results: ROSC was achieved in the field by 412/985 patients (41.8%). Of these, 411 (99.8%) were transported to hospital, 317 (76.9%) were admitted and 157 (38.1%) survived to hospital discharge. Among the 573 patients who did not achieve ROSC, 518 (90.4%) were transported to hospital, 32 (5.6%) were admitted and 5 (0.9%) survived to hospital discharge. No significant differences were noted for age, ethnicity, or other arrest characteristics, despite a trend toward female gender among those surviving to hospital admission despite not achieving ROSC when compared to those who did (44% vs. 29%, p = .11). The median length of stay for those who were admitted to hospital despite unsuccessful pre-hospital resuscitation was 3.0 days (1.5 days for those who did not survive). For those that were admitted to hospital after achieving ROSC in the field, the median length of stay was 8 days (2.0 days for those who did not survive). Conclusions: Despite unsuccessful resuscitation in the field, patients presenting with VF may survive to hospital discharge suggesting these patients should always be transported to hospital. Our data indicates that only a small burden would be placed on receiving hospitals in order to maximise the potential survival of such patients.

Purpose: A limited amount of data has been published regarding the effects of body weight on out-of-hospital cardiac arrest.1,2 We sought to describe the effects of obesity on ventricular fibrillation (VF) waveform characteristics, defibrillation, and outcomes. Methods: Between May 13, 2007 and June 30, 2009, the Fire Department of New York (FDNY) participated in a large, multicenter randomized controlled prehospital resuscitation study. Post-arrest interviews with the EMS providers including an assessment for "obesity," defined as 300 lbs or more. Data collected during the course of this study was used to assess the impact of obesity on cardiac arrest characteristics, including a calculated VF score based on the first five seconds of the rhythm analysis and representing the quality of the initial VF waveform. Results: A total of 4127 patients were enrolled by the FDNY during the study period, of whom 529 presented in VF of primary cardiac etiology. Data regarding the presence or absence of obesity was available all but 5 patients. Patients were considered to be significantly obese in 42/525 cases (8.0%). Obese patients were slightly though not significantly younger than non-obese patients (59.0 years vs 61.8 years). Initial waveform capnography values did not vary between the two groups (25.3 mmHg vs 25.6 mmHg). The median normalized VF score was similar among obese patients as compared to non-obese patients (.091, range .032–.312 versus .096, range .021–1.00, p = .48), while the average impedance was higher for obese patients (89.7 ohms vs 78.1 ohms). The average number of defibrillatory shocks for obese patients was less than that for the non-obese (1.48 vs 1.56, p = .035). Rates for return of spontaneous circulation, survival to hospital admission, and survival to hospital discharge did not vary between the two groups. Conclusions: Our data provides supporting evidence to suggest that obesity does not adverse effect VF characteristics, treatment or outcome.

Purpose: Racial disparities have been the focus of a number of healthcare studies to date, including those that have focused on out-of-hospital cardiac arrest (OOHCA).1,2 We sought to describe the characteristics and outcomes of OOHCA patients presenting in ventricular fibrillation (VF) as a function of race.Methods: Data collected by London Ambulance Service (LAS) and the Fire Department of New York (FDNY) between May 2006 and June 2009 as part of a randomized controlled prehospital resuscitation trial, including descriptions of each patient's race as described EMS personnel, was analyzed.Results: Data from 987 OOHCA patients presenting in VF of primary cardiac etiology were analyzed. Information regarding race was available for 854 (86.5%) patients. Non-white patients were significantly younger than white patients (LAS 60.0 years vs 68.3 years, FDNY 56.7 years vs 66.3 years, overall 57.2 years vs 67.5 years; max p < .001). In New York, nonwhite patients were less likely to receive bystander CPR as compared to white patients (19.9% vs 30.0%, p = .01). In London, no differences were noted with respect to the likelihood of receiving bystander CPR. There was no difference between nonwhites and whites for return of spontaneous circulation (LAS 41.3% vs 44.2%, p = .75; FDNY 43.1% vs 40.9%, p = .65; overall 42.8% vs 42.8%, p = 1.00) or survival to hospital admission (LAS 40.0% vs 38.6%, p = 0.87; FDNY 36.0% vs 31.3%, p = .30; overall 36.5% vs 35.5%, p = .77), though there was a trend toward improved survival to discharge among nonwhites (LAS 28.9% vs 17.0%, p = .07; FDNY 18.0% vs 13.0%, p = .14, overall 19.6% vs 15.3%, p = .13).Conclusions: Although no significant differences were noted with respect to outcome, the younger age and potential to improve bystander CPR rates for nonwhite patients represents cause for focused educational programs and community outreach as part of on-going efforts to improve cardiac arrest survival. Purpose: Racial disparities have been the focus of a number of healthcare studies to date, including those that have focused on out-of-hospital cardiac arrest (OOHCA).1,2 We sought to describe the characteristics and outcomes of OOHCA patients presenting in ventricular fibrillation (VF) as a function of race. Methods: Data collected by London Ambulance Service (LAS) and the Fire Department of New York (FDNY) between May 2006 and June 2009 as part of a randomized controlled prehospital resuscitation trial, including descriptions of each patient's race as described EMS personnel, was analyzed. Results: Data from 987 OOHCA patients presenting in VF of primary cardiac etiology were analyzed. Information regarding race was available for 854 (86.5%) patients. Non-white patients were significantly younger than white patients (LAS 60.0 years vs 68.3 years, FDNY 56.7 years vs 66.3 years, overall 57.2 years vs 67.5 years; max p < .001). In New York, nonwhite patients were less likely to receive bystander CPR as compared to white patients (19.9% vs 30.0%, p = .01). In London, no differences were noted with respect to the likelihood of receiving bystander CPR. There was no difference between nonwhites and whites for return of spontaneous circulation (LAS 41.3% vs 44.2%, p = .75; FDNY 43.1% vs 40.9%, p = .65; overall 42.8% vs 42.8%, p = 1.00) or survival to hospital admission (LAS 40.0% vs 38.6%, p = 0.87; FDNY 36.0% vs 31.3%, p = .30; overall 36.5% vs 35.5%, p = .77), though there was a trend toward improved survival to discharge among nonwhites (LAS 28.9% vs 17.0%, p = .07; FDNY 18.0% vs 13.0%, p = .14, overall 19.6% vs 15.3%, p = .13). Conclusions: Although no significant differences were noted with respect to outcome, the younger age and potential to improve bystander CPR rates for nonwhite patients represents cause for focused educational programs and community outreach as part of on-going efforts to improve cardiac arrest survival.

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