Log in to MyACC
Intra-Arrest Transport vs. Continued On-Scene Resuscitation in Out-of-Hospital Cardiac Arrest
Quick Takes
- Emergency medical systems vary considerably with respect to transport to the hospital during out-of-hospital cardiac arrest (OHCA) resuscitative efforts.
- In this cohort study that used a time-dependent propensity score-matched analysis including >27,700 patients with OHCA, intra-arrest transport compared with continued on-scene resuscitation had a probability of survival to hospital discharge of 4.0% vs. 8.5%.
- Although the study findings are limited by residual confounding to the observational design, this study does not support the routine practice of transporting patients during resuscitation from OHCA to the hospital.
Study Questions:
Is transport to the hospital during adult out-of-hospital cardiac arrest (OHCA) resuscitation compared with continued on-scene treatment associated with a difference in survival to hospital discharge?
Methods:
This was a cohort study of prospectively collected consecutive nontraumatic adult emergency medical system (EMS)-treated OHCA data from the Resuscitation Outcomes Consortium (ROC) Cardiac Epidemiologic Registry. Enrollment occurred from April 2011 to June 2015 from 10 North American sites with follow-up until the date of hospital discharge or death. Patients treated with intra-arrest transport were matched with patients in refractory arrest (at risk of intra-arrest transport) at that same time using a time-dependent propensity score. The primary outcome was survival to hospital discharge and the secondary outcome was survival with favorable neurological outcome (modified Rankin scale <3) at hospital discharge.
Results:
The full cohort study included 43,969 patients with a median age of 67 years (interquartile range, 55-80), 37% were women, 86% of cardiac arrests occurred in a private location, 49% were bystander- or EMS-witnessed, 22% had initial shockable rhythms, 97% were treated by out-of-hospital advanced life support, and 26% underwent intra-arrest transport. In the propensity-matched cohort (including 27,705 patients), survival to hospital discharge occurred in 4.0% of patients who underwent intra-arrest transport versus 8.5% who received on-scene resuscitation (risk difference, 4.6%; 95% confidence interval [CI], 4.0%-5.1%). Favorable neurological outcome occurred in 2.9% of patients who underwent intra-arrest transport versus 7.1% who received on-scene resuscitation (risk difference, 4.2%; 95% CI, 3.5%-4.9%).
Conclusions:
Among patients experiencing OHCA, intra-arrest transport to the hospital compared with continued on-scene resuscitation was associated with lower probability of survival to hospital discharge.
Perspective:
Adult OHCA remains a major public health burden worldwide with significant morbidity and mortality. In this study, Grunau and colleagues grapple with the question of whether to immediately transport OHCA patients during resuscitation efforts or to continue on-scene treatment until either return of spontaneous circulation or termination of efforts. The authors performed a secondary analysis using data from the large, multicenter ROC, which includes 10 study sites and nearly 200 EMS agencies in the United States and Canada. The authors found that in this time-dependent propensity score-matched analysis, intra-arrest transport to the hospital was associated with a significantly lower probability of survival to hospital discharge. However, the study results are confounded by multiple limitations and the paper ultimately serves as a call to action for more definitive evidence from pragmatic randomized controlled trials, recognizing the heterogeneity of patient populations and EMS systems around the world.
Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Cardiovascular Care Team, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias
Keywords: Acute Coronary Syndrome, Arrhythmias, Cardiac, Emergency Service, Hospital, Heart Arrest, Neurologic Manifestations, Out-of-Hospital Cardiac Arrest, Patient Discharge, Resuscitation, Secondary Prevention, Shock, Survival Analysis, Treatment Outcome
< Back to Listings
