Pre-hospital Post ROSC Care: Are we Achieving Our Targets?

Study Overview
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Brief Summary
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Rational: Out of hospital cardiac arrest is a devastating event with a high mortality. Survival rates have increased over the last years, with the availability of AED's and public BLS. Previous studies have shown that deranged physiology after return of spontaneous circulation (ROSC) is associated with a worse neurological outcome. Good quality post-arrest care is therefore of utmost importance. Objective: To determine how often prehospital crews (with their given skills set) encounter problems meeting optimal post-ROSC targets in patients suffering from OHCA, and to investigate if this can be predicted based on patient-, provider- or treatment factors. Study design: Prospective cohort study of all patients attended by the EMS services with an OHCA who regain ROSC and are transported to a single university hospital, in order to identify those patients with a ROSC after a non-traumatic OHCA who had deranged physiology and/or complications from OHCA EMS personnel was unable to prevent/deal with in the prehospital environment. Study population: Patients, >18 years, transported by the EMS services to the ED of the University Hospital Groningen (UMCG) with a ROSC after OHCA in a 1 year period Main study parameters/endpoints: Primary endpoint of our study is the percentage of OHCA patients with a prehospital ROSC who arrive in hospital with either a deranged physiology or with complications from OHCA EMS personnel was unable to deal with.

Official Title
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Which Patients With a ROSC After OHCA Would Potentially Benefit From Physician Driven Post Cardiac Arrest Care?

Conditions
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Out-Of-Hospital Cardiac Arrest, Post Cardiac Arrest Syndrome, Emergency Medical Services

Participation Criteria
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Eligibility Criteria
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Inclusion criteria: Non-traumatic OHCA (as confirmed in notes of ambulance crew) with ROSC obtained before transport to hospital Age > 18 Exclusion criteria: Traumatic cause of arrest (NB asphyxia due to hanging, electrocutions and drowning are not considered as traumatic arrests in this study, as normal ALS algorithms (special circumstances) are followed for these patients No ROSC before leaving OHCA Age <18 Informed opt out of medical research of patient

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| percentage of OHCA patients with a prehospital ROSC who arrive in hospital with either a deranged physiology or with complications from OHCA EMS personnel was unable to deal with | Any of the below 5 minutes or more after ROSC is obtained: -Airway intervention (SGA or ETT) not performed (when deemed necessary) Actively Vomiting in absence of ETT after ROSC B: -Hypoxia: -SaO2 <94% on at least two consecutive readings Hypercarbia: -ETCO2>5.5 kPa on at least two consecutive readings** C: -Low cardiac output: -Re-arrest during transport to hospital ETCO2<3.0 on two consecutive readings MAP<65mmHg on two consecutive readings SBP<100 mmHg on two consecutive readings upon arrival in ED D: -Hypoxic agitation upon arrival in ED or uncontrolled prehospital hypoxic agitation despite benzodiazepine administration or when benzodiazepines contraindicated) Seizures during transport E: -Hyperthermia | From pre-hospital ROSC to arrival at ED, approximately 1-2 hours | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Duration of period with deranged physiology, measured from moment of first occurrence until resolved or until arrival in hospital. | Any of the following measured in minutes: -Airway intervention (SGA or ETT) not performed (when deemed necessary) Actively Vomiting in absence of ETT after ROSC B: -Hypoxia: -SaO2 <94% on at least two consecutive readings Hypercarbia: -ETCO2>5.5 kPa on at least two consecutive readings** C: -Low cardiac output: -Re-arrest during transport to hospital ETCO2<3.0 on two consecutive readings MAP<65mmHg on two consecutive readings SBP<100 mmHg on two consecutive readings upon arrival in ED D: -Hypoxic agitation upon arrival in ED or uncontrolled prehospital hypoxic agitation despite benzodiazepine administration or when benzodiazepines contraindicated) Seizures during transport E: -Hyperthermia | From pre-hospital ROSC to arrival at ED, approximately 1-2 hours | 
| Patient- and resuscitation factors related to deranged physiology and/or complications in the post arrest phase |  | From pre-hospital ROSC to arrival at ED, approximately 1-2 hours | 
| Opinion of EMS providers weather or not they felt they were able to provide optimal post arrest care | Measured by a survey, filled out by EMS crew at arrival at ED | From pre-hospital ROSC to arrival at emergency department, approximately 1-2 hours | 
| Comparison of primary outcome of secondary outcomes between post ROSC patients attended by EMS only vs EMS and HEMS |  | From pre-hospital ROSC to arrival at emergency department, approximately 1-2 hours | 
| Frequency distribution of airway interventions (SGA or ETT) not performed (when deemed necessary) | -Airway intervention (SGA or ETT) not performed (when deemed necessary) in ED. NB NOT change of SGA for ETT when SGA is functioning well | From pre-hospital ROSC to arrival at emergency department, approximately 1-2 hours | 
| Frequency distribution of actively vomiting in absence of ETT after ROSC in prehospital setting |  | From pre-hospital ROSC to arrival at ED, approximately 1 to 2 hours | 
| Frequency distribution of the presence of hypoxia | SaO2 <94% on at least two consecutive readings | From pre-hospital ROSC to arrival at ED, approximately 1 to 2 hours | 
| Frequency distribution of low cardiac output | Presence of one of the following: Re-arrest during transport to hospital ETCO2<3.0 on two consecutive readings MAP<65mmHg on two consecutive readings 12 SBP<100 mmHg on two consecutive readings | From pre-hospital ROSC to ICU (or CCU) admission, up to about 1 hours | 
| Frequency distribution of hypoxic agitation upon arrival in ED or uncontrolled prehospital hypoxic agitation despite benzodiazepine administration or when benzodiazepines contraindicated) | Assessed by physician who enrolls patient | From pre-hospital ROSC to arrival at ED, approximately 1-2 hours | 
| Frequency distribution of seizures during transport |  | From pre-hospital ROSC to arrival at ED, approximately 1-2 hours | 
| Frequency distribution of the presence of hyperthermia | Defined as a temperature >37.5 celsius | From pre-hospital ROSC to arrival at ED, approximately 1-2 hours |