|Year : 2020 | Volume
| Issue : 1 | Page : 18-21
Adrenaline use as a poor predictor for the return of spontaneous circulation among victims of out-of-hospital cardiac arrest according to a national emergency medical services database
, Phatthranit Phattharapornjaroen1
, Woranee Kreethep1
, Chonnakarn Suwanmano1
, Chestsadakon Jenpanitpong1
, Rawin Nonnongku1 1 Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
2 Department of Medicine, Faculty of Medicine, Sleep Apnea Research Group, Khon Kaen University, Khon Kaen, Thailand
|Date of Submission||24-Sep-2019|
|Date of Acceptance||25-Sep-2019|
|Date of Web Publication||28-Jan-2020|
Prof. Kittisak Sawanyawisuth
Department of Medicine, Faculty of Medicine, Khon Kaen University, 123 Mitraparp Road, Khon Kaen 40002
Source of Support: None, Conflict of Interest: None
OBJECTIVE: This study aimed to determine additional predictors of cardiopulmonary resuscitation success using a national emergency medical services (EMS) database.
METHODS: This retrospective study was conducted by retrieving data from the Information Technology of Emergency Medical Service, a national EMS database. The inclusion criteria were adult patients (18 years old or over) who suffered from out-of-hospital cardiac arrest and received emergency life support. The outcome was a return of spontaneous circulation (ROSC). Predictors for ROSC were determined using multivariate logistic regression analysis.
RESULTS: During the study period, 1070 patients met the study criteria, among whom 199 (18.60%) belonged to the ROSC group. Five factors were eligible for multivariate logistic regression analysis for predicting ROSC. Accordingly, only adrenaline administration was independently and negatively associated with ROSC with an adjusted odds ratio of 0.722 (95% confidence interval: 0.522, 0.997) and a Hosmer–Lemeshow Chi-square of 5.84 (P = 0.665).
CONCLUSIONS: Adrenaline use may be a poor predictor for ROSC during out-of-hospital cardiac arrest.
Keywords: Adrenaline, cardiopulmonary resuscitation, outcomes
|How to cite this article:|
Yuksen C, Phattharapornjaroen P, Kreethep W, Suwanmano C, Jenpanitpong C, Nonnongku R, Sittichanbuncha Y, Sawanyawisuth K. Adrenaline use as a poor predictor for the return of spontaneous circulation among victims of out-of-hospital cardiac arrest according to a national emergency medical services database. Turk J Emerg Med 2020;20:18-21
|How to cite this URL:|
Yuksen C, Phattharapornjaroen P, Kreethep W, Suwanmano C, Jenpanitpong C, Nonnongku R, Sittichanbuncha Y, Sawanyawisuth K. Adrenaline use as a poor predictor for the return of spontaneous circulation among victims of out-of-hospital cardiac arrest according to a national emergency medical services database. Turk J Emerg Med [serial online] 2020 [cited 2021 Sep 19];20:18-21. Available from: https://www.turkjemergmed.org/text.asp?2020/20/1/18/276382
| Introduction|| |
A report from the American Heart Association (AHA) showed that 347,322 adults in the US suffered from out-of-hospital cardiac arrest in 2018, a number higher than that in 2011 (295,000 cases)., Among the reported cases, approximately 60% were treated by emergency medical services (EMS), 68.5% occurred at home, and 37% were witnessed by a layperson. While EMS-treated, out-of-hospital cardiac arrests have a survival rate of 10.8%, several factors have been associated with survival among such victims.
Early cardiopulmonary resuscitation (CPR) has been the key factor for survival among victims of out-of-hospital cardiac arrest. A previous study found that only 32% of victims suffering from out-of-hospital cardiac arrest received CPR from a layperson, with automated external defibrillators being used in only 2.1% use of the victims. The median survival rate from ventricular fibrillation was higher than that from other rhythms (21% vs. 7.9%). In addition, among 10 North American study sites for out-of-hospital cardiac arrest, survival rates varied from 3.0% to 16.3%. These data indicated that several factors are associated with survival among victims of out-of-hospital cardiac arrest. This study therefore aimed to identify predictors of CPR success using a national EMS database.
| Methods|| |
This retrospective study was conducted by retrieving data from the Information Technology of Emergency Medical Service (ITEMS), a national EMS database of the National Institute for Emergency Medicine (Thailand). The inclusion criteria were adult patients (18 years old or over) who suffered from both traumatic and nontraumatic out-of-hospital cardiac arrest and received emergency life support and airway management by EMS staff in a prehospital setting. Pregnant women or terminally ill patients with do-not-attempt-resuscitation orders were excluded from the study. The study was conducted from November 2016 to October 2017.
The ITEMS database was searched for eligible patients using the code “cardiac arrest,” subsequently enrolling those who met with the inclusion criteria. Clinical baseline characteristics, treatments, and outcome were recorded. Data were categorized according to either bag-valve-mask ventilation or endotracheal tube intubation. The studied variables included gender, age, response time, on-scene time (min), distance from the scene, defibrillation, fluid therapy, adrenaline administration, and cause of cardiac arrest (internal medicine, surgery, or accident). The studied outcome was a return of spontaneous circulation (ROSC). The ROSC outcome was evaluated at the emergency department of the respective hospitals.
Clinical data of eligible patients were analyzed and categorized according to the ROSC. Univariate logistic regression analysis was utilized to calculate the crude odds ratio (OR) of individual variables for ROSC. Factors with P < 0.20 during univariate logistic regression were subsequently included in multivariate logistic regression analysis. Analytical results were presented as crude OR, adjusted OR, and 95% confidence intervals (CIs). The goodness of fit of the multivariate logistic regression model was tested using the Hosmer–Lemeshow method. All data analyses were performed using STATA software (StataCorp LP, College Station, TX, USA).
| Results|| |
During the study period, 1070 patients met the study criteria, among whom 199 (18.60%) belonged to the ROSC group [Table 1]. Four significant factors were identified between those with and without ROSC, including age and proportion of patients receiving intravenous fluid, adrenaline administration, and medical illness. The ROSC group was younger (50.84 vs. 53.99 years; P = 0.041) and had significantly lower proportions of adrenaline administration (43.2% vs. 51.9%) and medical illnesses (54.3% vs. 63.0%) than the no ROSC group (P = 0.028 for both the factors).
|Table 1: Baseline characteristics and factors of patients suffering from out-of-hospital cardiac arrest registered in the Information Technology of Emergency Medical Service database categorized according to the return of spontaneous circulation|
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Five factors were eligible for multivariate logistic regression analysis to predict the ROSC [Table 2]. However, only adrenaline administration was independently and negatively associated with ROSC, with an adjusted OR of 0.722 (95% CI: 0.522, 0.997) and a Hosmer–Lemeshow Chi-square of 5.84 (P = 0.665). As shown in [Table 3], seven factors differed significantly between those who did and did not receive adrenaline. Those who received adrenaline were older (55.01 vs. 51.77 years), received more intravenous fluids (98.3% vs. 90.9%), and had higher proportions of medical illnesses (68.0% vs. 54.7%) and endotracheal intubations (33.2% vs. 17.1%) than those who did not receive adrenaline.
|Table 2: Predictors for return of spontaneous circulation in patients suffering from out-of-hospital cardiac arrest registered in the Information Technology of Emergency Medical Service database|
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|Table 3: Baseline characteristics and factors of patients suffering from out-of-hospital cardiac arrest registered in the Information Technology of Emergency Medical Service database categorized according to the adrenaline administration|
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| Discussion|| |
The ROSC rate reported herein was slightly higher than the survival rate reported by the 2018 report by the AHA. This difference in outcome may be because of the use of CPR for the evaluation of ROSC in the present study, which was higher than the survival rate obtained from hospitals in the AHA report. A study from Korea found that a telephone CPR program increased bystander CPR from 2.9% to 10.3% and the ROSC rate from 1.4% to 4.3%. However, the ROSC rate in the aforementioned was much lower than that presented herein because of differences in CPR provider, that is, EMS personnel executed CPR herein, whereas laypersons performed CPR in the Korean study. The ROSC rate in the present study was somewhat higher than that in a previous study, wherein CPR was performed by EMS technicians (5.8%). The high ROSC rate in the current study could perhaps be attributed to the high response time (almost 50% within 8 min) as shown in [Table 1].
Several predictors for good outcomes have been identified among patients with out-of-hospital cardiac arrest, including ventricular fibrillation/tachycardia, serum creatinine, or serum lactate. The current study found that adrenaline use reduced the likelihood for ROSC by 28% [Table 2]. These data may indicate that most patients may have had unshockable rhythms, resulting in low ROSC rates. One previous study found that ventricular fibrillation/tachycardia rhythm resulted in more individuals having good than poor outcomes (70% vs. 27%; P < 0.05). Another possible reason could be that victims receiving more adrenaline may have had a more severe condition than those received less adrenaline. As shown in [Table 3], those who received adrenaline were older and received delayed treatment as evidenced by the longer travel distance from the scene. The increased number of endotracheal intubations and medical illnesses among those receiving adrenaline may also suggest a more severe condition compared to those not receiving adrenaline. A study from Poland found that young patients suffering from out-of-hospital cardiac arrests had higher rates of ROSC than other age groups (65.81% vs. 58.87%; P = 0.005). Shorter response time has also been another factor associated with ROSC. One previous study found that among patients suffering from out-of-hospital cardiac arrest, those with ROSC had significantly shorter response time compared to those without ROSC (370 vs. 394 s; P = 0.015).
Some limitations of the present study are worth noting. First, only information from the ITEMS database had been analyzed. Second, limited data had been available on the type of cardiac arrhythmia or CPR providers. Prehospital CPR teams in our country consist of two types: basic or advanced teams. Accordingly, basic CPR teams may provide limited treatment, excluding adrenaline administration or defibrillation. Second, only endotracheal tubes or bag-valve masks were used herein. Finally, some data, such as intravenous fluid types and amount of fluid therapy or comorbid diseases,,,, might have been missing because of retrospective data collection.
| Conclusions|| |
Our findings suggest that adrenaline use may be a poor predictor for ROSC among victims of out-of-hospital cardiac arrest.
Author contribution statement
1. Conceived and designed the experiments: CY, YS, KS. 2. Performed the experiments: CY, PP, WK, CS, CJ, RN, YS. 3. Analyzed and interpreted the data: CY, KS. 4. Contributed reagents, materials, analysis tools or data: CY. 5. Wrote the pape: CY, KS
Conflicts of interest
The authors declare no conflict of interest.
| References|| |
Roger VL, Go AS, Lloyd-Jones DM, Adams RJ, Berry JD, Brown TM, et al.
Heart disease and stroke statistics–2011 update: A report from the American Heart Association. Circulation 2011;123:e18-209.
Benjamin EJ, Virani SS, Callaway CW, Chamberlain AM, Chang AR, Cheng S, et al.
Heart disease and stroke statistics-2018 update: A report from the American Heart Association. Circulation 2018;137:e67-492.
Weisfeldt ML, Sitlani CM, Ornato JP, Rea T, Aufderheide TP, Davis D, et al.
Survival after application of automatic external defibrillators before arrival of the emergency medical system: Evaluation in the resuscitation outcomes consortium population of 21 million. J Am Coll Cardiol 2010;55:1713-20.
Nichol G, Thomas E, Callaway CW, Hedges J, Powell JL, Aufderheide TP, et al.
Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA 2008;300:1423-31.
Lee YJ, Hwang SS, Shin SD, Lee SC, Song KJ. Effect of national implementation of telephone CPR program to improve outcomes from out-of-hospital cardiac arrest: An interrupted time-series analysis. J Korean Med Sci 2018;33:e328.
Hasegawa K, Hiraide A, Chang Y, Brown DF. Association of prehospital advanced airway management with neurologic outcome and survival in patients with out-of-hospital cardiac arrest. JAMA 2013;309:257-66.
Adrie C, Cariou A, Mourvillier B, Laurent I, Dabbane H, Hantala F, et al.
Predicting survival with good neurological recovery at hospital admission after successful resuscitation of out-of-hospital cardiac arrest: The OHCA score. Eur Heart J 2006;27:2840-5.
Rzońca P, Gałązkowski R, Panczyk M, Gotlib J. Polish Helicopter Emergency Medical Service (HEMS) response to out-of-hospital cardiac arrest (OHCA): A retrospective study. Med Sci Monit 2018;24:6053-8.
Do HQ, Nielsen SL, Rasmussen LS. Response interval is important for survival until admission after prehospital cardiac arrest. Dan Med Bull 2010;57:A4203.
Senthong V, Kukongviriyapan U, Settasatian N, Settasatian C, Komanasin N, et al
. Prevalence and characteristics of metabolic syndrome in northeast Thai patients with obstructive coronary artery disease. Asia Pac J Sci Technol 2016;21:77-85.
Sawunyavisuth B. What are predictors for a continuous positive airway pressure machine purchasing in obstructive sleep apnea patients? Asia Pac J Sci Technol 2018;23:APST-23-03-10.
Churak P, Praditsorn P, Meenongwah J, Wimonpeerapattana W. Factors associated with nutritional status of elderly in Ubon Ratchathani, Thailand. Asia Pac J Sci Technol 2019;24:APST-24-01-08.
Wangsan K, Chaiear N, Sawanyawisuth K, Klainin P, Simajareuk K. Pattern of shiftwork and health status among nurses in a university hospital in Northeastern Thailand. Asia Pac J Sci Technol 2019;24:APST-24-02-08.
[Table 1], [Table 2], [Table 3]