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Association of Intra-arrest Transport vs Continued On-Scene Resuscitation With Survival to Hospital Discharge Among Patients With Out-of-Hospital Cardiac Arrest

Educational Objective
To understand the benefits of on-scene resuscitation for out-of-hospital cardiac arrest.
1 Credit CME
Key Points

Question  Is transport to hospital during adult out-of-hospital cardiac arrest resuscitation compared with continued on-scene treatment associated with a difference in survival to hospital discharge?

Findings  In this cohort study that used a time-dependent propensity score–matched analysis including 27 705 patients with out-of-hospital cardiac arrest, intra-arrest transport compared with continued on-scene resuscitation had a probability of survival to hospital discharge of 4.0% vs 8.5%, a difference that was statistically significant.

Meaning  These results do not support the practice of routinely transporting patients during resuscitation from out-of-hospital cardiac arrest to the hospital.

Abstract

Importance  There is wide variability among emergency medical systems (EMS) with respect to transport to hospital during out-of-hospital cardiac arrest (OHCA) resuscitative efforts. The benefit of intra-arrest transport during resuscitation compared with continued on-scene resuscitation is unclear.

Objective  To determine whether intra-arrest transport compared with continued on-scene resuscitation is associated with survival to hospital discharge among patients experiencing OHCA.

Design, Setting, and Participants  Cohort study of prospectively collected consecutive nontraumatic adult EMS-treated OHCA data from the Resuscitation Outcomes Consortium (ROC) Cardiac Epidemiologic Registry (enrollment, April 2011-June 2015 from 10 North American sites; follow-up until the date of hospital discharge or death [regardless of when either event occurred]). Patients treated with intra-arrest transport (exposed) were matched with patients in refractory arrest (at risk of intra-arrest transport) at that same time (unexposed), using a time-dependent propensity score. Subgroups categorized by initial cardiac rhythm and EMS-witnessed cardiac arrests were analyzed.

Exposures  Intra-arrest transport (transport initiated prior to return of spontaneous circulation), compared with continued on-scene resuscitation.

Main Outcomes and Measures  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 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. Survival to hospital discharge was 3.8% for patients who underwent intra-arrest transport and 12.6% for those who received on-scene resuscitation. In the propensity-matched cohort, which included 27 705 patients, survival to hospital discharge occurred in 4.0% of patients who underwent intra-arrest transport vs 8.5% who received on-scene resuscitation (risk difference, 4.6% [95% CI, 4.0%- 5.1%]). Favorable neurological outcome occurred in 2.9% of patients who underwent intra-arrest transport vs 7.1% who received on-scene resuscitation (risk difference, 4.2% [95% CI, 3.5%-4.9%]). Subgroups of initial shockable and nonshockable rhythms as well as EMS-witnessed and unwitnessed cardiac arrests all had a significant association between intra-arrest transport and lower probability of survival to hospital discharge.

Conclusions and Relevance  Among patients experiencing out-of-hospital cardiac arrest, intra-arrest transport to hospital compared with continued on-scene resuscitation was associated with lower probability of survival to hospital discharge. Study findings are limited by potential confounding due to observational design.

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Article Information

Corresponding Author: Brian Grunau, MD, MHSc, Department of Emergency Medicine, St Paul’s Hospital, 1081 Burrard St, Vancouver, BC V6Z 1Y6, Canada (brian.grunau@ubc.ca).

Accepted for Publication: July 15, 2020.

Author Contributions: Drs Leroux and Kime had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Grunau, Kime, van Belle, Menegazzi, Kudenchuk, Vaillancourt, Morrison, Elmer, Austin, Richmond, Herren.

Acquisition, analysis, or interpretation of data: Grunau, Kime, Leroux, Rea, van Belle, Menegazzi, Kudenchuk, Vaillancourt, Morrison, Elmer, Le, Richmond, Herren, Christenson.

Drafting of the manuscript: Grunau, Kime, van Belle, Menegazzi.

Critical revision of the manuscript for important intellectual content: Kime, Leroux, Rea, van Belle, Menegazzi, Kudenchuk, Vaillancourt, Morrison, Elmer, Le, Austin, Richmond, Herren, Christenson.

Statistical analysis: Kime, Leroux, van Belle, Elmer.

Obtained funding: Christenson.

Administrative, technical, or material support: Grunau, Rea, Menegazzi, Vaillancourt, Le, Richmond, Herren, Christenson.

Supervision: Rea, Kudenchuk, Richmond, Christenson.

Conflict of Interest Disclosures: Dr Grunau is the principal investigator of a clinical trial investigating the benefit of intra-arrest transport to hospital for extracorporeal CPR initiation (NCT02832752). Dr Grunau has received speaking honorarium from Stryker Corp. Dr Menegazzi is supported by grant 1RO1HL117979 from the National Heart, Lung, and Blood Institute. In his laboratory, he uses a monitor/defibrillator loaned to him by Zoll Medical Corporation, and a mechanical chest compression device loaned to him by Stryker Corp. He has no financial interest in either of these 2 companies. Dr Morrison received salary support from the National Institutes of Health (NIH) for the duration of the Resuscitation Outcomes Consortium–funded network. She holds peer-reviewed grants in cardiac arrest resuscitation from the Canadian Institute of Health Research and the Heart and Stroke Foundation of Canada. Dr Elmer has support from the NIH through grants 5K12HL109068 and 1K23NS097629. Dr Kudenchuk is the primary investigator of the National Institute for Neurological Disorders and Stroke Strategies to Innovate Emergency Care Clinical Trials Network (NINDS-SIREN). No other disclosures were reported.

Funding/Support: The Resuscitation Outcomes Consortium was supported by the National Heart, Lung, and Blood Institute in partnership with the National Institute of Neurological Disorders and Stroke, US Army Medical Research and Material Command, the Canadian Institutes of Health Research (CIHR) – Institute of Circulatory and Respiratory Health, Defence Research and Development Canada, the Heart and Stroke Foundation of Canada, and the American Heart Association through a series of cooperative agreements with 9 regional clinical centers and 1 data coordinating center (University of Washington Data Coordinating Center [5U01 HL077863]; Medical College of Wisconsin [HL077866]; University of Washington [HL077867]; University of Pittsburgh [HL077871]; St. Michael’s Hospital [HL077872]; Oregon Health and Science University [HL077873]; University of Alabama at Birmingham [HL077881]; Ottawa Health Research Institute [HL077885]; University of Texas SW Medical Center/Dallas [HL077887]; University of California San Diego [HL077908]).

Role of the Funder/Sponsor: The above sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We would like to acknowledge the commitment and dedication of out-of-hospital first responders and professionals, hospital-based clinicians, and the Resuscitation Outcomes Consortium research office, to the best possible treatment of cardiac arrest victims.

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