BACKGROUND: Out-of-hospital cardiac arrest (OHCA) is a major public health problem. This study aims to describe the international variations in the practices related to the initiation, termination, and refraining from resuscitation of adult patients (≥18 years) with a non-traumatic OHCA. METHODS: An exploratory descriptive study was conducted using a cross-sectional online survey. The respondents were recruited using snowball sampling technique. Framework analysis was used to identify key themes in responses, with descriptive statistics summarising data trends. RESULTS: The study collected responses from 59 countries. Our findings reveal that respondents from 59.3% of countries reported that they initiate resuscitation in all cases where the patients do not show obvious signs of irreversible death or do not have confirmed advance directives. Respondents from 15.3% of countries reported that once started, prehospital resuscitation attempts are not terminated. Prehospitally respondents from 20.3% of the countries reported that they rely exclusively on specific criteria to decide when to terminate resuscitation efforts while in 45.8%, these decisions are made at the discretion of the provider. Respondents from most countries (91.5%) reported that they refrain from resuscitation in the presence of obvious signs of irreversible death. Respondents from 57.6% of countries, reported that they refrained from resuscitation if the patient had a confirmed do-not-attempt-cardiopulmonaryresuscitation (DNACPR), while 15.3% mentioned staff safety as a reason to abstain from attempting resuscitation. CONCLUSION: This study reveals global variation in EMS resuscitation practices, reflecting disparities in resources, healthcare infrastructure, EMS system design, community acceptability given cultural and societal norms, and legislation.

• Keywords
• Emergency care disparities, Health policies, Health system capacity, Termination of resuscitation (TOR),
• Publication type
• Journal Article MeSH

Sudden cardiac arrest remains a relevant problem with a significant number of deaths worldwide. Although survival rates have more than tripled over the last 20 years (4% in 2001 vs. 14% in 2020), survival rates with good neurological outcomes remain persistently low, representing a major socioeconomic problem. Every minute of delay from patient collapse to start cardiopulmonary resuscitation (CPR) and early defibrillation reduces the chance of survival by approximately 10-12%. Therefore, the time to treatment is a crucial factor in the prognosis of patients with out-of-hospital cardiac arrest (OHCA). Research teams working in the pre-hospital setting are therefore looking for ways to improve the transmission of information from the site of an emergency event and to make it easier for emergency medical dispatch centres (EMDC) to recognise life-threatening conditions with minimal deviation. For emergency unit procedures already at the scene of the event, methods are being sought to efficiently and temporarily replace a non-functioning cardiopulmonary system. In the case of traumatic cardiac arrest (TCA), the focus is mainly on effective affecting non-compressible haemorrhage.

• Keywords
• ECPR, OHCA, REBOA, artificial intelligence, drones and AED, pre-hospital blood transfusion, video emergency calls,
• MeSH
• Time-to-Treatment MeSH
• Cardiopulmonary Resuscitation * methods   MeSH
• Humans MeSH
• Emergency Medical Services * MeSH
• Out-of-Hospital Cardiac Arrest * therapy   MeSH
• Check Tag
• Humans MeSH
• Publication type
• Journal Article MeSH
• Review MeSH

BACKGROUND: Trans-nasal evaporative cooling is an effective method to induce intra-arrest therapeutic hypothermia in out-of-hospital cardiac arrest (OHCA). The use of supraglottic airway devices (SGA) instead of endotracheal intubation may enable shorter time intervals to induce cooling. We aimed to study the outcomes in OHCA patients receiving endotracheal intubation (ETI) or a SGA during intra-arrest trans-nasal evaporative cooling. METHODS: This is a pre-specified sub-study of the PRINCESS trial (NCT01400373) that included witnessed OHCA patients randomized during resuscitation to trans-nasal intra-arrest cooling vs. standard care followed by temperature control at 33 °C for 24 h. For this study, patients randomized to intra-arrest cooling were stratified according to the use of ETI vs. SGA prior to the induction of cooling. SGA was placed by paramedics in the first-tier ambulance or by physicians or anesthetic nurses in the second tier while ETI was performed only after the arrival of the second tier. Propensity score matching was used to adjust for differences at the baseline between the two groups. The primary outcome was survival with good neurological outcome, defined as cerebral performance category (CPC) 1-2 at 90 days. Secondary outcomes included time to place airway, overall survival at 90 days, survival with complete neurologic recovery (CPC 1) at 90 days and sustained return of spontaneous circulation (ROSC). RESULTS: Of the 343 patients randomized to the intervention arm (median age 64 years, 24% were women), 328 received intra-arrest cooling and had data on the airway method (n = 259 with ETI vs. n = 69 with SGA). Median time from the arrival of the first-tier ambulance to successful airway management was 8 min for ETI performed by second tier and 4 min for SGA performed by the first or second tier (p = 0.001). No significant differences in the probability of good neurological outcome (OR 1.43, 95% CI 0.64-3.01), overall survival (OR 1.26, 95% CI 0.57-2.55), full neurological recovery (OR 1.17, 95% CI 0.52-2.73) or sustained ROSC (OR 0.88, 95% CI 0.50-1.52) were observed between ETI and SGA. CONCLUSIONS: Among the OHCA patients treated with trans-nasal evaporative intra-arrest cooling, the use of SGA was associated with a significantly shorter time to airway management and with similar outcomes compared to ETI.

• Keywords
• airway management, cardiac arrest, intra-arrest hypothermia,
• Publication type
• Journal Article MeSH

BACKGROUND: In concordance with the results of large, observational studies, a 2015 European survey suggested variation in resuscitation/end-of-life practices and emergency care organization across 31 countries. The current survey-based study aimed to comparatively assess the evolution of practices from 2015 to 2019, especially in countries with "low" (i.e., average or lower) 2015 questionnaire domain scores. METHODS: The 2015 questionnaire with additional consensus-based questions was used. The 2019 questionnaire covered practices/decisions related to end-of-life care (domain A); determinants of access to resuscitation/post-resuscitation care (domain B); diagnosis of death/organ donation (domain C); and emergency care organization (domain D). Responses from 25 countries were analyzed. Positive or negative responses were graded by 1 or 0, respectively. Domain scores were calculated by summation of practice-specific response grades. RESULTS: Domain A and B scores for 2015 and 2019 were similar. Domain C score decreased by 1 point [95% confidence interval (CI): 1-3; p = 0.02]. Domain D score increased by 2.6 points (95% CI: 0.2-5.0; p = 0.035); this improvement was driven by countries with "low" 2015 domain D scores. In countries with "low" 2015 domain A scores, domain A score increased by 5.5 points (95% CI: 0.4-10.6; p = 0.047). CONCLUSIONS: In 2019, improvements in emergency care organization and an increasing frequency of end-of-life practices were observed primarily in countries with previously "low" scores in the corresponding domains of the 2015 questionnaire.

• Keywords
• emergency care, ethics, resuscitation, surveys and questionnaires, terminal care,
• Publication type
• Journal Article MeSH

IMPORTANCE: Out-of-hospital cardiac arrest (OHCA) has poor outcome. Whether intra-arrest transport, extracorporeal cardiopulmonary resuscitation (ECPR), and immediate invasive assessment and treatment (invasive strategy) is beneficial in this setting remains uncertain. OBJECTIVE: To determine whether an early invasive approach in adults with refractory OHCA improves neurologically favorable survival. DESIGN, SETTING, AND PARTICIPANTS: Single-center, randomized clinical trial in Prague, Czech Republic, of adults with a witnessed OHCA of presumed cardiac origin without return of spontaneous circulation. A total of 256 participants, of a planned sample size of 285, were enrolled between March 2013 and October 2020. Patients were observed until death or day 180 (last patient follow-up ended on March 30, 2021). INTERVENTIONS: In the invasive strategy group (n = 124), mechanical compression was initiated, followed by intra-arrest transport to a cardiac center for ECPR and immediate invasive assessment and treatment. Regular advanced cardiac life support was continued on-site in the standard strategy group (n = 132). MAIN OUTCOMES AND MEASURES: The primary outcome was survival with a good neurologic outcome (defined as Cerebral Performance Category [CPC] 1-2) at 180 days after randomization. Secondary outcomes included neurologic recovery at 30 days (defined as CPC 1-2 at any time within the first 30 days) and cardiac recovery at 30 days (defined as no need for pharmacological or mechanical cardiac support for at least 24 hours). RESULTS: The trial was stopped at the recommendation of the data and safety monitoring board when prespecified criteria for futility were met. Among 256 patients (median age, 58 years; 44 [17%] women), 256 (100%) completed the trial. In the main analysis, 39 patients (31.5%) in the invasive strategy group and 29 (22.0%) in the standard strategy group survived to 180 days with good neurologic outcome (odds ratio [OR], 1.63 [95% CI, 0.93 to 2.85]; difference, 9.5% [95% CI, -1.3% to 20.1%]; P = .09). At 30 days, neurologic recovery had occurred in 38 patients (30.6%) in the invasive strategy group and in 24 (18.2%) in the standard strategy group (OR, 1.99 [95% CI, 1.11 to 3.57]; difference, 12.4% [95% CI, 1.9% to 22.7%]; P = .02), and cardiac recovery had occurred in 54 (43.5%) and 45 (34.1%) patients, respectively (OR, 1.49 [95% CI, 0.91 to 2.47]; difference, 9.4% [95% CI, -2.5% to 21%]; P = .12). Bleeding occurred more frequently in the invasive strategy vs standard strategy group (31% vs 15%, respectively). CONCLUSIONS AND RELEVANCE: Among patients with refractory out-of-hospital cardiac arrest, the bundle of early intra-arrest transport, ECPR, and invasive assessment and treatment did not significantly improve survival with neurologically favorable outcome at 180 days compared with standard resuscitation. However, the trial was possibly underpowered to detect a clinically relevant difference. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01511666.

• MeSH
• Time-to-Treatment MeSH
• Cardiopulmonary Resuscitation methods   MeSH
• Middle Aged MeSH
• Humans MeSH
• Extracorporeal Membrane Oxygenation MeSH
• Aged MeSH
• Transportation of Patients * MeSH
• Out-of-Hospital Cardiac Arrest diagnosis   mortality   therapy   MeSH
• Medical Futility MeSH
• Check Tag
• Middle Aged MeSH
• Humans MeSH
• Male MeSH
• Aged MeSH
• Female MeSH
• Publication type
• Journal Article MeSH
• Research Support, Non-U.S. Gov't MeSH
• Randomized Controlled Trial MeSH

These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.

UNLABELLED: Diese Ethikleitlinien des Europäischen Rats für Wiederbelebung enthalten evidenzbasierte Empfehlungen für die ethische, routinemäßige Praxis der Wiederbelebung und für die Betreuung von Erwachsenen und Kindern am Lebensende. Die Leitlinie konzentriert sich in erster Linie auf wichtige Maßnahmen in Bezug auf ethische Praktiken (d. h. Patientenverfügung, vorausschauende Behandlungsplanung* und gemeinsame Entscheidungsfindung), die Entscheidungsfindung in Bezug auf Wiederbelebung, Ausbildung und Forschung. Diese Bereiche stehen in engem Zusammenhang mit der Anwendung der Prinzipien der Bioethik in der Praxis der Wiederbelebung und der Betreuung am Lebensende. ZUSATZMATERIAL ONLINE: Zusätzliche Informationen sind in der Online-Version dieses Artikels (10.1007/s10049-021-00888-8) enthalten.

• Keywords
• Advance care planing, Advance directives, Shared decision making,
• Publication type
• English Abstract MeSH
• Journal Article MeSH
• Review MeSH

BACKGROUND: In Europe, survival-rates after out-of-hospital cardiac arrest (OHCA) vary widely between regions. Whether a system dispatching First Responders (FRs; main FR-types: firefighters, police officers, citizen-responders) is present or not may be associated with survival-rates. This study aimed to assess the association between having a dispatched FR-system and rates of return of spontaneous circulation (ROSC) and survival across Europe. METHODS: Results of an inventory of dispatched FR-systems for OHCA in Europe were combined with aggregate ROSC and survival data from the EuReCa-TWO study and additionally collected data. Regression analysis (weighted on number of patients included per region) was performed to study the association between having a dispatched FR-system and ROSC and survival-rates to hospital discharge in the total population and in patients with shockable initial rhythm, witnessed OHCA and bystander cardiopulmonary resuscitation (CPR; Utstein comparator group). For regions without a dispatched FR-system, the theoretical survival-rate if a dispatched FR-system would have existed was estimated. FINDINGS: We included 27 European regions. There were 15,859 OHCAs in the total group and 2,326 OHCAs in the Utstein comparator group. Aggregate ROSC and survival-rates were significantly higher in regions with an FR-system compared to regions without (ROSC: 36% [95%CI 35%-37%] vs. 24% [95%CI 23%-25%]; P<0.001; survival in total population [N=15.859]: 13% [95%CI 12%-15%] vs. 5% [95%CI 4%-6%]; P<0.001; survival in Utstein comparator group [N=2326]: 33% [95%CI 30%-36%] vs. 18% [95%CI 16%-20%]; P<0.001), and in regions with more than one FR-type compared to regions with only one FR-type. All main FR-types were associated with higher survival-rates (all P<0.050). INTERPRETATION: European regions with dispatched FRs showed higher ROSC and survival-rates than regions without. FUNDING: This project/work has received funding from the European Union's Horizon 2020 research and innovation programme under acronym ESCAPE-NET, registered under grant agreement No 733381 (IO, HLT and MTB) and the European Union's COST programme under acronym PARQ, registered under grant agreement No CA19137 (IO, DC, HLT, MTB). HLT and MTB were supported by a grant from the Netherlands CardioVascular Research Initiative, Dutch Heart Foundation, Dutch Federation of University Medical Centres, Netherlands Organization for Health Research and Development, Royal Netherlands Academy of Sciences - CVON2017-15 RESCUED (HLT), and CVON2018-30 Predict2 (HLT and MTB).

• Publication type
• Journal Article MeSH