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Out-of-hospital cardiac arrest 2


Out-of-hospital cardiac arrest: prehospital management
Marcus Eng Hock Ong, Gavin D Perkins, Alain Cariou

Lancet 2018; 391: 980–88 Sudden out-of-hospital cardiac arrest is the most time-critical medical emergency. In the second paper of this Series
This is the second in a Series of on out-of-hospital cardiac arrest, we considered important issues in the prehospital management of cardiac arrest.
three papers about Successful resuscitation relies on a strong chain of survival with the community, dispatch centre, ambulance, and
out-of-hospital cardiac arrest
hospital working together. Early cardiopulmonary resuscitation and defibrillation has the greatest impact on survival.
Department of Emergency If the community response does not restart the heart, resuscitation is continued by emergency medical services’ staff.
Medicine, Singapore General
Hospital, Singapore
However, the best approaches for airway management and the effectiveness of currently used drug treatments are
(M E H Ong MPH); Health uncertain. Prognostic factors and rules for termination of resuscitation could guide the duration of a resuscitation
Services and Systems Research, attempt and decision to transport to hospital. If return of spontaneous circulation is achieved, the focus of treatment
Duke-NUS Medical School,
shifts to stabilisation, restoration of normal physiological parameters, and transportation to hospital for ongoing care.
Singapore (M E H Ong);
Warwick Clinical Trials Unit,
Warwick Medical School, Introduction Role of the community working with dispatch
University of Warwick, Out-of-hospital cardiac arrest (OHCA) is a global health CPR in the community
Coventry, UK (G D Perkins MD);
problem, with survival varying greatly between The earlier CPR is started in OHCA, the more likely it is
Heart of England NHS
Foundation Trust, communities.1,2 The chain of survival provides a useful that the patient will survive.6 In a study from Ontario,
Birmingham, UK (G D Perkins); concept to understand differences in prehospital systems Canada, the OPALS investigators4 concluded that by­
Medical Intensive Care Unit, of emergency care that result in such variations in stander CPR was the most important modifiable factor
AP-HP, Cochin Hospital, Paris,
survival.3 Survival of patients with OHCA requires a for survival after OHCA (odds ratio [OR] 2·98, 95% CI
France (Prof A Cariou MD); and
Paris Descartes University, coordinated set of actions, including immediate 2·07–4·29).
Paris, France (Prof A Cariou) recognition of cardiac arrest and activation of the Conventional strategies to improve the frequency of
Correspondence to: emergency response system, early cardiopulmonary bystander CPR require a concerted public health effort to
Dr Marcus Eng Hock Ong, resuscitation (CPR), rapid defibrillation, effective ad­ educate and train the population to perform CPR. These
Department of Emergency
vanced life support, and integrated care after cardiac strategies might include mandatory requirements for
Medicine, Singapore General
Hospital, Singapore 169856 arrest. The chain of survival encompasses the commun­ CPR training in schools or to obtain a driver’s licence (eg,
marcus.ong.e.h@singhealth. ity, emergency medical dispatch, and ambulance and Seattle, WA, USA). In general, they are labour intensive
com.sg hospital-based services. The medical literature has and require a long-term approach to achieve positive
focused more on hospital and advanced life support outcomes.7 It is also a relatively costly strategy,
treatments than it has on community treatment and considering the large number of people that need to be
issues related to basic life support (figure 1). However, trained to achieve any improvement in delivery of
there has been increasing recognition of the importance bystander CPR.8 Despite large-scale training efforts in
of basic life support, the role of the community, and communities, reported rates of bystander CPR have been
the key function of emergency medical dispatch in low, for reasons including difficulty in identifying cardiac
coordination of bystander CPR and early defibrillation.4,5 arrest, fear of causing harm, emotional distress, and
reluctance to perform mouth-to-mouth resuscitation.9
The dispatch centre (also known as the control room
Search strategy and selection criteria or call centre) has a central role in the coordination of the
In this Series paper, we consider the prehospital management response to OHCA (figure 2). In many ways, it is the
of out-of-hospital cardiac arrest, with a focus on the first links brain of the emergency medical services (EMS) and
in the chain of survival. We searched the Cochrane Library, determines the subsequent dispatch of resources and
MEDLINE, and Embase from Jan 1, 2001, to Dec 31, 2017, with response to an OHCA.
the terms “cardiac arrest” or “resuscitation” in combination Dispatcher-assisted CPR is an attractive intervention to
with “dispatch”, “ambulance”, “pre-hospital”, “emergency increase CPR rates and survival.10 When a bystander calls
medical services”, “defibrillation”, or “cardio-pulmonary the emergency medical response number to request for
resuscitation”. Our search was restricted to English-language help, they create an opportunity for early identification of
publications only. We largely selected publications from the OHCA and provision of bystander CPR.11 The medical
past 10 years, but did not exclude commonly referenced older dispatcher is thus the true first responder at the scene,
publications. We also searched the reference lists of articles and can be key to prompt recognition of cardiac arrest and
identified by this search strategy and selected those we judged initiation of bystander CPR. This strategy requires proper
relevant. Our reference list was modified on the basis of training of dispatchers to ask the right questions, manage
comments from peer reviewers. the emotional state of the caller, and give clear instructions.
Giving just-in-time education over the telephone can

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provide callers with step-by-step instructions on how to Current relative emphasis on elements in the chain of survival

H
perform CPR.
Dispatcher-assisted CPR programmes can nearly
double the frequency of bystander CPR.12 Change in
protocols to compression-only CPR have enabled dis­
patchers to give simple instructions for rescuing adults in AED
sudden cardiac arrest.13 Dispatch-assisted, compression-
only CPR results in reduced delay in starting CPR,
increased participation, and improved outcomes in
early cardiac arrest.14 In Singapore, a comprehensive
programme of dispatcher-assisted CPR (which included H
dispatcher training focusing on communication and
persuasion, review of audio recordings of all OHCA calls, AED
giving feedback to dispatchers, and public education on
dispatcher-assisted CPR) doubled bystander CPR rates
Survival impacts of elements in the chain of survival
and increased survival after OHCA.15
Figure 1: Current relative emphasis versus effect on survival of elements in the chain of survival
Problems with recognition of cardiac arrest by the public AED=automated external defibrillator.
and the dispatcher
One of the main barriers to timely initiation of EMS Public-access defibrillation
response and initiation of CPR is difficulty the general The key challenge to improve strategies that increase
public has in recognising OHCA, and similarly challenges public access to defibrillation is how to link willing lay
for dispatchers to diagnose OHCA over the telephone.16 responders to public-access defibrillators. Installation of
In particular, a patient in cardiac arrest might still have public-access automated external defibrillators (AEDs)
gasping movements, due to agonal breathing that can be without linking them to responders might not improve
misinterpreted as normal respiration.12 This difficulty has survival. However, community-wide programmes that
led to the development of “no, no, go” protocols by EMS integrate public training on CPR with increased access to
systems such as that of Seattle, USA,17 which have been AEDs, for example in Japan,19 have increased the odds of
increasingly adopted elsewhere in the USA, Europe, neurologically intact survival.
South Korea, Taiwan, and Singapore. These pro­ tocols Although cost is still a potential barrier to dissemination
emphasise deliberate initiation of dispatcher-assisted of AEDs, strategic placement of AEDs could be a more
CPR instructions if the response to two initial questions pressing issue. For example, Folke and colleagues16
is no: “is the person conscious?” and “is the person estimated that, for the city of Copenhagen, 1104 AEDs
breathing normally?”. Such protocols have substantially would be required to cover 67% of arrests with the cost
increased the delivery of bystander CPR.18 However, these per quality-adjusted life-year gained being US$40 900.22
protocols also increase the likelihood that a person who is However, this cost could possibly be reduced with use of
not in cardiac arrest might receive chest compressions, smart technologies to link existing AEDs with lay
although in practice this possibility has not resulted in responders.
any reported adverse outcomes. In the near future, video- One exciting development in recent years has been the
assisted dispatch technologies might enhance the ability potential of smartphone technology to amplify the effect
of dispatchers to recognise OHCA. of volunteer first responders and public AEDs. A national
registry of AEDs that is available to the public is a crucial
Public education, community CPR, and defibrillation prerequisite for success. Ringh and colleagues23 showed
training that mobile-phone positioning to alert volunteers to the
There has been increasing understanding that prompt location of AEDs significantly increased rates of bystander-
CPR and defibrillation is important for OHCA survival, initiated CPR for OHCAs. Smartphone technology can
irrespective of who performs it.19 Reduction of ambulance help trained bystanders to locate both the patient and the
response times is challenging for most EMS systems, nearest AED. In a world where smartphones are common,
and might not be a cost-effective policy to improve application of this technology could be a potential game
survival.20 Simplified training programmes have changer. Another interesting possibility in the near future
shown potential to actively recruit lay people into is that of AEDs mounted on drones, sent to bystanders
community efforts. For example, a large public campaign performing CPR.24
focusing on compression-only CPR in Arizona, USA,
was successful in increasing bystander CPR rates as well Decision to resuscitate
as survival.21 The aim should not be to dilute the quality Early descriptions of resuscitation described its application
of CPR training, but to extend the reach into the for “hearts that are too good to die”.25 Resuscitation
community to build a pyramid of responders (figure 3). started promptly has the greatest chance of success.

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First responder Public-access AED


smart technology defibrillation

Dispatcher-
assisted CPR
EMS response
H
Patient with Post-resuscitation
Active citizens
cardiac arrest care

Figure 2: Systems approach to improving survival after cardiac arrest


CPR=cardiopulmonary resuscitation. AED=automated external defibrillator. EMS=emergency medical services.

Pyramid of first responder normal breathing (and absence of a central pulse


preparedness for those experienced in central pulse palpation), chest
Lay or compressions (5–6 cm depth, rate 100–120 per min,
volunteer CPR with minimal interruptions) are delivered while
and AED instructors
Move lay cardiac monitoring is established (figure 4).32 If the
bystanders
Certified CPR and AED training
initial rhythm is ventricular fibrillation or ventricular
this way
Anyone who attends and passes a tachycardia, defibrillation is attempted followed by
certified (>3 h) CPR and AED course immediate resumption of chest compressions. For
non-shockable rhythms (pulseless electrical activity
Community awareness: Simplified CPR and AED training
everyone becomes aware of what Anyone who has attended a simplified (<1 h) and asystole) chest compressions are continued. Before
CPR is, and how to follow course emphasising dispatcher-assisted CPR and AED use securing the airway, chest compressions are paused
instructions from EMS dispatchers
every 30 compressions to allow the delivery of
Figure 3: Building a pyramid of first responder preparedness two ventilations.33,34 Once the airway is secured,
All training programmes referred to include hands-on practice and not just exposure to theory. con­tinuous chest compressions with intermittent
CPR=cardiopulmonary resuscitation. AED=automated external defibrillator. EMS=emergency medical services. ventilations are recommended.34
There is controversy about the optimal approach to
If resus­ citation efforts are delayed (as often occurs in airway management in OHCA. Observational studies
unwitnessed cardiac arrest or when no bystander CPR is have produced conflicting results when comparing
provided), the chances of successful resuscitation are basic (eg, bag–valve–mask) with advanced airways (eg,
substantially reduced. intu­bation or supraglottic airways).35–37 The training and
International approaches differ in the decision to ex­perience of the operator undertaking airway manage­
commence or continue resuscitation. In many but not ment is probably an important contributing factor.38
all settings, resuscitation will be withheld if there is The recently completed AIRWAYS-239 and PART40 trials
evidence of irreversible death (eg, rigor mortis, dependent will provide valuable information about the optimal
lividity [hypostasis], or unsurvivable injuries).26 In some approach to airway management in OHCA.
countries, adverse prognostic factors (eg, unwitnessed Medication has featured in cardiac arrest algorithms
cardiac arrest, no bystander CPR for more than 15 min, since their inception. However, two landmark studies
or asystolic rhythm and the absence of a potentially found no evidence that drugs improved outcomes.41,42
reversible cause such as hypothermia) permit resus­ The Ontario Pre-hospital Advanced Life Support
citation to be withheld,27 when in other countries (OPALS) study41 examined outcomes before and after
resuscitation would be provided in such circumstances.28 the introduction of advanced resuscitation techniques
In some jurisdictions, advanced decisions by patients to (intubation and drugs). The investigators found no
withhold resuscitation might have to be recorded before evidence of improved survival (5·0% before intro­
cardiac arrest although their use in the community is duction of advanced measures vs 5·1% after their intro­
much less common than in hospitals.29–31 duction, p=0·83) or favourable neurological outcome
(3·9% vs 3·4%, p=0·73). Olasveengen and colleagues42
EMS response and interventions (including randomly assigned 916 patients to resuscitation with
pharmacotherapeutic interventions) intravenous or without intravenous drugs. Patients
Resuscitation efforts by health-care professionals usually allocated to the intravenous drug group were more
follow the Universal Treatment Algorithm.31 After con­ likely to have return of spontaneous circulation
firmation of cardiac arrest by identifying the absence of (OR 1·99, 95% CI 1·48–2·67) but were no more likely to

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survive (1·16, 0·74–1·82) or survive with favourable


neurological outcome (1·24, 0·77–1·98). Confirm cardiac arrest
Epinephrine is often given to patients in shockable
rhythms who are refractory to attempted defibrillation,
High-quality CPR
and to those in non-shockable rhythms. The rationale
for administration is that it increases aortic diastolic
pressure and improves coronary perfusion. Findings Attach monitoring
from experimental studies, however, suggest that it
could impair cerebral blood flow, increase ventricular
Assess rhythm
arrhythmias, and induce myocardial dysfunction after
return of spontaneous circulation.43 Early resuscitation
algorithms recommended admin­ istration of 0·5 mg
epinephrine intracardiac or 10 mg intravenously.44 Sub­ Shockable Consider and treat High-quality CPR: Non-shockable
sequent data from randomised controlled trials showed reversible causes: Chest compressions
Hypoxia of 5–6cm
no benefit to high-dose epinephrine, leading to the dose Hypovolaemia Rate of chest
being reduced to 1 mg every 3–5 min.45 Jacobs and Hyperkalaemia compressions
Hypothermia or 100–120 min–1
colleagues46 compared 1 mg epinephrine every 3–5 min hyperthermia Avoid leaning
with placebo in a randomised controlled trial in Australia. Thromboembolism Minimal
Deliver shock ×1 Toxins interrupti ons
The trial enrolled 601 adults with OHCA of any cause, Tension Ventilations 10 min–1
when resuscitation was started by paramedics. The trial pneumothorax Manage airway
faced recruitment challenges and closed after enrolment Continue CPR 2 min Tamponade Consider drug Continue CPR 2 min
of only 10% of the intended sample size. The study
showed evidence of improved return of spontaneous No ROSC
circulation with epinephrine (OR 3·4, 95% CI 2·0–5·6) Re-assess rhythm and restart loop
but no difference in long-term survival (2·2, 0·7–6·3). Consider prognostic factors
Continue, terminate, or transport
The PARAMEDIC2 trial,47 which compared 1 mg
epinephrine every 3–5 min with placebo, closed to
recruitment in October, 2017, and will provide further ROSC
Start post-resuscitation care
information about the safety and effectiveness of Transport to hospital
adrenaline.47
The potent vasopressor, vasopressin, has been studied
as an alternative or adjunctive treatment to epinephrine Figure 4: Advanced life support treatment algorithm
for cardiac arrest. A meta-analysis48 of trials that in total CPR=cardiopulmonary resuscitation. ROSC=return of spontaneous circulation.
enrolled over 6000 patients found no improvement in
outcomes compared with epinephrine, prompting the Manual versus mechanical CPR
International Liaison Committee on Resuscitation to High-quality CPR is crucial for optimal outcomes after
recommend against its routine use in cardiac arrest.49 cardiac arrest, yet it is physically demanding and difficult
Anti-arrhythmic drugs are recommended when initial to sustain. Mechanical chest compression devices auto­
attempts at defibrillation do not achieve return of mate the process and deliver consistent, high-quality
spontaneous circulation. The randomised controlled chest compressions. Two devices have been evaluated in
ALPS trial50 treated 3026 patients with shock-refractory large, multicentre, prehospital clinical trials that enrolled
OHCA, with amiodarone, lidocaine, or placebo. Although 12 206 patients with OHCA.51 The Autopulse device
there was no difference in the primary outcome of (Zoll Medical, Chelmsford, MA, USA) consists of a
survival to discharge or favourable neurological outcome load-distributing band encircling the patient’s chest and
in the overall trial population, outcomes were better in squeezing it against a rigid back­board. The LUCAS device
those who received drugs if the cardiac arrest was (Physio-Control and Jolife AB, Lund, Sweden) uses a
witnessed by a bystander or EMS than in those who piston and suction cup to deliver compressions with active
received drugs but were not witnessed by a bystander or recoil. None of the trials individually or when combined
EMS. Compared with placebo, survival was 5% (95% CI in meta-analyses found improved rates of return of
0·3–9·7) higher in the amiodarone group and spontaneous circulation (OR 0·96, 95% CI 0·85–1·10),
5·2% (0·5–9·9) higher in the lidocaine group survival at hospital discharge or after 30 days (0·89,
for bystander-witnessed cardiac arrest. There was no 0·77–1·02), or favourable neurological outcome (0·76,
difference between amiodarone and lidocaine.50 The 0·53–1·11).52 These findings led the International Liaison
special formulation of amiodarone used in this trial Committee on Resuscitation to not recommend the
(which causes less hypotension) is not widely available, routine use of mechanical chest compression devices.49
limiting the generalisability of this aspect of the study Despite the absence of benefit from strategies that
findings at present. routinely deploy mechanical chest compression in

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neurological outcome when return of spontaneous


Panel: Rules for termination of resuscitation in basic and circulation occurred after 47 min. Similar observations
advanced life support were made in a Japanese registry study involving
Basic life support (all criteria must be present) 282 183 bystander-witnessed cases of OHCA.56
• Event not witnessed by emergency medical services In the past few decades, it became necessary to
personnel provide clinical prediction rules for the termination of
• No automated external defibrillator used or manual shock resuscitation to avoid futile transports. Consequently,
applied in out-of-hospital setting several teams have developed and prospectively tested
• No return of spontaneous circulation in out-of-hospital termination of resuscitation rules, which can be applied
setting by prehospital health-care providers even in the absence
of a physician (panel).57–60
Advanced life support (all criteria must be present)
• Event not witnessed by emergency medical services When to stop initial resuscitation efforts?
personnel The termination of resuscitation guidelines were
• No automated external defibrillator used or manual shock originally developed for prehospital providers of basic life
applied in out-of-hospital setting support in selection of individuals in whom continued
• No return of spontaneous circulation in out-of-hospital resuscitation and transport to hospital would be futile.57
setting Since then, the guideline for termination of resuscitation
• Arrest not witnessed by bystander in basic life support has been prospectively and externally
• No bystander-administered cardiopulmonary resuscitation validated in several studies with both basic and advanced
providers of life support, and is commonly referred to as
the universal termination of resuscitation guideline.58–60 It
OHCA, there remain situations in which manual chest states that resuscitation can be discon­tinued in the field
compressions are either not possible or hazardous by prehospital providers if the following three criteria are
in which it is reasonable to consider mechanical CPR. met: the cardiac arrest was not witnessed by EMS
Examples include during land ambulance or helicopter providers; the patient did not show return of spontaneous
transfer to hospital, during percutaneous coronary circulation despite attempted resuscitation; and no
intervention, and as a bridge to advanced therapies (eg, shocks were delivered (ie, a non-shockable rhythm) at any
extracorporeal CPR). Mechanical CPR has also been used time before transport. A prospective validation of the
to maintain organ perfusion when resuscitation has been guideline showed good specificity and positive predictive
unsuccessful before organ donation. If mechanical CPR value for futility, while reducing the transport frequency
is deployed it is important that interruptions to chest to 46% of attempted resuscitations by EMS.58 In addition
compressions are kept to a minimum (<10–20 s). to the universal guideline for termination of resuscitation
Training resuscitation teams in a pit-stop approach, with in basic life support, a universal guideline for advanced
a focus on non-technical skills, can substantially reduce life support has been developed. This guideline adds
interruptions to CPR during deployment.53 two criteria to the basic life support rule: arrest not
witnessed by bystander; and no bystander-administered
Refractory arrest CPR. Findings from a large validation study60 established
Transport or termination of resuscitation that both rules accurately identified patients with OHCA
There are no absolute rules on the optimal duration of who were unlikely to benefit from prolonged CPR
resuscitation. Factors associated with improved outcomes and transport to the hospital for further attempts at
(eg, witnessed arrest, initial shockable rhythm, bystander resuscitation. Use of these decisions to stop resuscitative
CPR) or the presence of potentially reversible causes, efforts could substantially decrease the number of
could guide clinicians to continue with resuscitation futile emergency EMS transports without appreciably
efforts for longer. In an analysis of CPR duration, Grunau worsening survival.
and colleagues54 showed that the elapsed duration at
which the probability of survival fell below 1% was 48 min Extracorporeal CPR
in patients with shockable rhythms and 15 min in those Extracorporeal CPR is being used increasingly when
with non-shockable rhythms. A secondary analysis55 conventional resuscitation efforts fail to achieve return
of 11 368 cases of OHCA from the US ROC-PRIMED of spontaneous circulation, with encouraging results.61
(Resuscitation Outcomes Consortium Prehospital Resus­ Several ongoing randomised studies are comparing
citation Using an Impedance Valve and Early Versus extracorporeal CPR with conventional CPR to establish
Delayed) study identified that, with conventional if this is an effective strategy in refractory cardiac
resuscitation, 90% of patients with good outcome arrest.62 Interestingly, one of these ongoing trials
achieved initial return of spontaneous circulation within aims to show that extracorporeal CPR can be provided
20 min and 99% of those with good outcomes achieved it on the resuscitation scene, outside the hospital
within 37 min. There were no survivors with favourable (NCT 02527031).63

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Whichever technique is used, the decision to establish hypothermia.11,23,68–70 Although the intervention decreased
extracorporeal CPR should be made early (within 10 min) mean core temperature on admission and reduced the
and only in patients in whom there is a reasonable chance time to achieve the targeted temperature, it did not prove
of neurological recovery26 according to simple criteria: beneficial and was associated with a significant increase
witnessed arrest; CPR provided by witness; ventricular in adverse events.11 On the basis of this evidence,
tachycardia or ventricular fibrillation (ie, shockable prehospital cooling with rapid infusion of large volumes
rhythms) as presenting rhythm; presumed reversible of cold intravenous fluid immediately after return of
cause (eg, cardiac [particularly coronary causes], toxic, spontaneous circulation is not recommended.
hypothermia); no evidence for severe underlying
condition; and available mechanical CPR device. Early Ventilation
activation of the process is essential to reduce the delay to The vast majority of patients with return of spontaneous
extracorporeal CPR. In the most impressive case series circulation need endotracheal intubation and mechanical
reported to date, patients who received an extracorporeal ventilation. Particular attention should be paid to ventilator
CPR strategy started the mechanical assistance after a settings. Avoidance of hypoxaemia is the main goal, but
mean delay of 64 min after the OHCA.64 considering the evidence of harm after myocardial
infarction71 and the possibility of increased neurological
Optimisation of care after resuscitation injury after cardiac arrest,72,73 it is recom­mended that the
Management priorities inspired oxygen concentration maintains arterial blood
Guidelines from European Resuscitation Council (ERC) oxygen saturation in the range of 94–98%. Because CO2
and European Society of Intensive Care Medicine arterial pressure might affect cerebral blood flow, both
(ESICM)65 provide information about how to optimise hypocapnia and hypercapnia should be avoided by
the management of the post-resuscitation syndrome. adjusting tidal volumes and respiratory rate. Adjustment
Post-resuscitation care should start at the location where of ventilation to achieve normocarbia can be facilitated by
return of spontaneous circulation is achieved. The most monitoring the end-tidal CO2 during transport.
important management priorities in the prehospital
setting are circulatory, respiratory, and temperature. In Triage and orientation
parallel, all efforts should be made to bring the patient to Many resuscitated patients will develop a post-resuscitation
the most appropriate receiving centre. disease, requiring ICU admission. Identification and
treatment of the cause of the arrest is a priority that
Circulation might be difficult to achieve in all hospitals. When there is
Shock is very common in the post-resuscitation period, evidence for a coronary cause, as reflected by ECG patterns
resulting from the combination of transient myocardial or symptoms reported by the patient before arrest
dysfunction and vasoplegia caused by whole-body suggestive of a coronary cause, it is highly recommended
ischaemia reperfusion.66 Fluids and norepinephrine, with to send these patients to an available cardiac catheterisation
or without dobutamine, are usually the most effective laboratory.74 In such patients nearly all clinical data
treatments. Infusion of relatively large volumes of fluid is converge to indicate a benefit associated with early
tolerated remarkably well by patients with post-cardiac- coronary reperfusion.75 Since the publication of the
arrest syndrome. In the most severely unwell patients pioneering study by Spaulding and colleagues,76 which was
with refractory shock, the implantation of a mechanical the first to show a benefit for angioplasty after cardiac
circulatory assistance might be useful.20 Importantly, arrest, findings from several studies have shown that
finding and treating the cause of the arrest is of major immediate evaluation in the cardiac catheter laboratory,
importance to control post-resuscitation shock. with early percutaneous coronary intervention when
indicated, is associated with improved outcomes, includ­
Temperature control ing survival and neurological recovery.77 In patients
Targeted temperature management—the maintenance with no clinical or electrical evidence for a coronary
of a target temperature between 32°C and 36°C for at cause, the benefit of the early invasive strategy is de­
least 24 h—is strongly recommended.65 The supporting bated and the answer will probably come from
evidence is based on experimental animal data, non- the several on­ going trials (DISCO [NCT02309151],
randomised clinical studies, and two small randomised EMERGE [NCT02876458], COACT [NTR4973],
trials.6,67 Furthermore, this strategy applies mostly to TOMAHAWK [NCT02750462], COUPE [NCT02641626],
comatose adult patients after OHCA with an initial and PEARL [NCT02387398]) examining this issue. Early
shockable rhythm, whereas the indication is debated in identification of a respiratory or neurological cause would
patients with an initial non-shockable rhythm. enable transfer of the patient to a specialised ICU for
The usefulness of targeted temperature management optimal care and might help in assessment of prognosis
during transport has been examined in clinical studies and appropriate treatment.78 In comatose patients, a
in which cold intravenous fluids were administered careful prognostication process is recommended, which
after return of spontaneous circulation to induce should be based on multimodal evaluation.79 Withdrawal

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of life-sustaining therapy because of perceived poor 10 Rea TD, Eisenberg MS, Culley LL, Becker L. Dispatcher-assisted
neurological prognosis is a common cause of hospital cardiopulmonary resuscitation and survival in cardiac arrest.
Circulation 2001; 104: 2513–16.
death after OHCA. Although current guidelines recom­ 11 Kim F, Nichol G, Maynard C, et al. Effect of prehospital induction of
mend against with­drawal of life-sustaining therapy before mild hypothermia on survival and neurological status among adults
72 h, this practice is common and could increase mortality.80 with cardiac arrest: a randomized clinical trial. JAMA 2014; 311: 45–52.
12 Vaillancourt C, Verma A, Trickett J, et al. Evaluating the effectiveness
of dispatch-assisted cardiopulmonary resuscitation instructions.
Conclusion Acad Emerg Med 2007; 14: 877–83.
Survival from OHCA remains poor globally. Strength­en­ 13 Berg RA, Hemphill R, Abella BS, et al. Part 5: adult basic life support:
2010 American Heart Association Guidelines for Cardiopulmonary
ing of the early links in the chain of survival (ie, cardiac Resuscitation and Emergency Cardiovascular Care. Circulation 2010;
arrest recognition, call for help, bystander CPR, and 122 (suppl 3): S685–705.
bystander AED use) have the greatest potential to 14 Hallstrom A, Cobb L, Johnson E, Copass M. Cardiopulmonary
resuscitation by chest compression alone or with mouth-to-mouth
improve survival. If return of spontaneous circulation ventilation. N Engl J Med 2000; 342: 1546–53.
occurs, the focus shifts from resuscitation to stabilisation 15 Harjanto S, Na MX, Hao Y, et al. A before-after interventional trial of
and transfer to a specialist facility. dispatcher-assisted cardio-pulmonary resuscitation for out-of-hospital
cardiac arrests in Singapore. Resuscitation 2016; 102: 85–93.
Contributors
16 Ho AF, Sim ZJ, Shahidah N, et al. Barriers to dispatcher-assisted
MEHO wrote the introduction and section on the role of the community.
cardiopulmonary resuscitation in Singapore. Resuscitation 2016;
GDP wrote the section on the emergency medical services’ response. 105: 149–55.
AC wrote the section on the optimisation of care. All authors were 17 Hauff SR, Rea TD, Culley LL, Kerry F, Becker L, Eisenberg MS.
involved in the conception, writing, and editing of the manuscript. Factors impeding dispatcher-assisted telephone cardiopulmonary
Declaration of interests resuscitation. Ann Emerg Med 2003; 42: 731–37.
MEHO is currently scientific adviser to Global Healthcare SG and 18 Zive D, Koprowicz K, Schmidt T, et al. Variation in out-of-hospital
TIIM SG, and holds patents related to using heart rate variability and cardiac arrest resuscitation and transport practices in the
artificial intelligence for medical monitoring. He has no direct conflicts Resuscitation Outcomes Consortium: ROC Epistry-Cardiac Arrest.
Resuscitation 2011; 82: 277–84.
relating to sections written by him. GDP received support as a National
Institute of Health Research Senior (NIHR) Investigator and has led 19 Kitamura T, Iwami T, Kawamura T, et al. Nationwide public-access
defibrillation in Japan. N Engl J Med 2010; 362: 994–1004.
studies relating to quality of cardiopulmonary resuscitation (CPR),
mechanical CPR, and drugs in cardiac arrest funded by NIHR. He has 20 de Chambrun MP, Brechot N, Lebreton G, et al. Venoarterial
extracorporeal membrane oxygenation for refractory cardiogenic
volunteer roles with the UK and European Resuscitation Councils and
shock post-cardiac arrest. Intensive Care Med 2016; 42: 1999–2007.
the International Committee for Resuscitation. AC received fees for
21 Bobrow BJ, Spaite DW, Berg RA, et al. Chest compression-only CPR
lectures from Bard and AstraZeneca. He has no direct conflicts relating
by lay rescuers and survival from out-of-hospital cardiac arrest.
to sections written by him.
JAMA; 304: 1447–54.
Acknowledgments 22 Folke F, Lippert FK, Nielsen SL, et al. Location of cardiac arrest in a
We thank Andrew Fu Wah Ho and Pek Pin Pin for their contributions to city center: strategic placement of automated external defibrillators in
the literature review and preparation of this manuscript. We thank public locations. Circulation 2009; 120: 510–17.
Charles Deakin for the concept depicted in figure 1. 23 Bernard SA, Smith K, Cameron P, et al. Induction of therapeutic
hypothermia by paramedics after resuscitation from out-of-hospital
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