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Jaroslav Kajzr

Out-of-hospital cardiac arrest Pilot study: baseline demographic data and quality of care assessment in pre-hospital setting in Eastern Bohemia Region. Jaroslav Kajzr. Sudden cardiac death. Sudden , non-traumatic death caused by cardiac disease 1 hour after symptoms onset

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Jaroslav Kajzr

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  1. Out-of-hospital cardiac arrest Pilot study: baseline demographic data and quality of care assessment in pre-hospital setting in Eastern Bohemia Region Jaroslav Kajzr Endorsed by Grant of Ministry of Health No. 7254-3

  2. Sudden cardiac death • Sudden, non-traumatic deathcaused by cardiac disease • 1 hour after symptoms onset • Heart disease may be known, but time and reason for death is unpredictable • Incidence in USA and Europe is 0,1 – 0,5/1000, varies in different regions • Mortality77 -100% (dependent on SCD definition, health care system, inclusion criteria ,..., most often roundabout 94 % Endorsed by Grant of Ministry of Health No. 7254-3

  3. Relation between risk of SCD and baseline risk stratification according to predefined subgroups Endorsed by Grant of Ministry of Health No. 7254-3

  4. Eastern Bohemia Region • Was unknown regarding: • Incidence of SCD • Data extrapolated from small studies in single centres with different criteria for SCD, successful resuscitation, etc. • Need for ICD implantation, EPS, ... • Financial issues • Organisation and quality of care on different levels • → Grant of Ministry of Health Endorsed by Grant of Ministry of Health No. 7254-3

  5. Method • Prospective study • 2002 – 2004 (25 months) • Data collected with unique questionnaire • To protect patient data – coding • ACCES database • Regular check up of medical documentation and comparison with questionnaire • Statistical analysis Endorsed by Grant of Ministry of Health No. 7254-3

  6. Semily Trutnov Náchod Rychnov Hradec Králové nad Kněžnou Pardubice Ústí nad Orlicí Chrudim Svitavy Havlíčkův Brod Region • 11 244 km² • 1 240 000 inhabitants • Unhomogennic region • 24 pre-hospital care centres; 2 cardiac centres;19 internal medicine dept; 16 A&E Endorsed by Grant of Ministry of Health No. 7254-3

  7. SCD: circardian variation 60 50 40 30 rate 20 10 0 0 2 4 6 8 10 12 14 16 18 20 22 hours SCD: age distribution and gender Number 140 120 100 Males 80 60 40 Females 20 0 18- 20- 30- 40- 50- 60- 70- 80- 90- age 19 29 39 49 59 69 79 89 99 Patients • N = 703, ♂ N = 501 (71,3 %); median69 year of age; (18 – 93), IHD 83% • Home n = 487 (69,3%),street n = 104 (14,8 %), n = 112 (15,9%) other place Endorsed by Grant of Ministry of Health No. 7254-3

  8. Utstein style protocol • Population n = 1 200 000 inhabitants • Confirmed SCD n = 703 • ALS = 560; (79,7%) • Death on the spot n = 350 (63%) • Death during the transport n = 61 (11%) • Death in hospital n = 96 (17%) Endorsed by Grant of Ministry of Health No. 7254-3

  9. Utstein style protocol • Witnessed arrest n = 495 • Initial rhythm: • VF n = 210 • VT n = 11 • Asystole n = 218 • Other n = 56 • ROSC yes n = 203 • ROSC no n = 292 • Hospital admission n = 136 • Hospital deaths n = 88 • Discharged n = 48 • Non-witnessed arrest • Initial rhythm • VF n = 17 • VT n = 0 • Asystole n = 46 • Other n = 2 • ROSC yes n = 18 • ROSC no n = 47 • Hospital admission n = 13 • Hospital deaths n = 8 • Discharged n = 5 Endorsed by Grant of Ministry of Health No. 7254-3

  10. ALS group • ALS n = 560 (79,7%) • BystanderCPR +: n = 203 (36,3%); survival: n = 26 (12,8%); bystander CPR-: n = 357 (63,8 %); survival n = 27 (7,6%); p = 0,042 • (Day-time ALS +: n = 447 (79,8%);night-time: ALS +: n = 113 (79 %); p = 0,83 • Median of age in ALS group: 68 y, medianof age in no ALS group: 74 y; p < 0,001) Endorsed by Grant of Ministry of Health No. 7254-3

  11. Utstein style protocol • Discharged from hospital n = 53 (9,5 %) • No or minimal neurological deficit n = 35 (66 %) Endorsed by Grant of Ministry of Health No. 7254-3

  12. Factors influencing a survival rate Endorsed by Grant of Ministry of Health No. 7254-3

  13. Symptoms onset – medical aid time Endorsed by Grant of Ministry of Health No. 7254-3

  14. Time: symptoms onset - depature Endorsed by Grant of Ministry of Health No. 7254-3

  15. Emergency call – departure time • All group n = 703:median = 1 min • [the longest = 4 min (n = 8)] • ALS x non ALS: median 1 min. (p = 0,638) • Day: 1 min. x night: 2 min. (p = < 0,001) Endorsed by Grant of Ministry of Health No. 7254-3

  16. Arrival time • Emergency call – beginning of professional aid Endorsed by Grant of Ministry of Health No. 7254-3

  17. Arrival time - medians • Median time 8 (1 – 43) min • ALS group = 7,5; non-ALS group = 10 min; p = 0,0049 • Survivors = 6 min, non-survivors 8 min; p = 0,003 • VF = 7 min vsasystoly = 9 min, p = 0,001 • Daytime: 8 min, night-time: 10 min; p = 0,0016 • Differences in centres 4 – 13 min.; p < 0,001 Endorsed by Grant of Ministry of Health No. 7254-3

  18. Výsledek ALS v závislosti na denní době; n = 560 500 398 400 300 Exitus Přežití 200 109 100 49 4 0 1 2 1 noc, 2 den, rozdíl v přežití (3,7 % vs. 12,3 % p = 0,018) Mortality rate: dayx night in ALS group Endorsed by Grant of Ministry of Health No. 7254-3

  19. Discussion: symptoms onset - medical aid time interval • Median time of 15 min in day-time andof 18 min in night-timeis very long • Affected by late emergency calls,long departure time and also to long arrival times • Night-time doesn`t affect a decision not to start with ALS but does affect the result of ALS in terms of mortality rate Endorsed by Grant of Ministry of Health No. 7254-3

  20. Discussion: symtoms onset – emergency call • Median of 8 min is to long • It is the same time as time required for transport of medical crew despite the fact that almost 80% SCD where witnessed • Whiteness do not recognise hemodynamic arrest symptoms, do not know emergency call numbers, do not know what to do Endorsed by Grant of Ministry of Health No. 7254-3

  21. Discussion: departure time • Immediate reaction of crews in most centres • Internal guidelines are properly followed Endorsed by Grant of Ministry of Health No. 7254-3

  22. Discussion: arrival time • The shorter arrival median time, the better overall results =  ALS +  survival • Medianin survivors = 6 min, VF 7 min • This time interval appears to be one of the most potent predictive factors for survival in this study • Median = 8 min • Still good result in comparison with results from abroad, • National guidelines are followed in high • Median arrival time is still to long if seen in the light of brain death • In few centres there is unacceptably long departure time • It reflects a situation in the distributionof centres  any changes required??? Endorsed by Grant of Ministry of Health No. 7254-3

  23. Conclusion • This study shows particularly good availability of medical care in region • Generally no delays happen in professional pre-hospital care • Guidelines are followed at high degree • Dismal mortality rate was expectable, but is still good in comparison with other published data (average survival 0,5 – 2%) • Problem is low public awareness regarding SCD Endorsed by Grant of Ministry of Health No. 7254-3

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