EMS MEd Blog

Article Bites #14: To Tube or Not to Tube in Cardiac Arrest?

Article: Benger JR, Kirby K, Black S, et al. Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome: The AIRWAYS-2 Randomized Clinical Trial. JAMA. 2018;320(8):779-791.


The benefit of advanced life support measures in the management of patients with out-of-hospital cardiac arrest (OHCA) is controversial. Endotracheal intubation has long been considered the mainstay of definitive airway control in patients with cardiac arrest, however, there is a growing body of evidence to suggest that alternative airway interventions such as the implementation of supraglottic devices (i.e. laryngeal mask airways) may be of value. This is likely due to the ease in which these devices can be placed, and requirement for less training to obtain proficiency compared to endotracheal intubation. Studies looking at head to head comparisons of endotracheal intubation versus the use of supraglottic devices in OHCA are lacking. The primary goal of this study was to compare the difference in modified Rankin Scale (mRS) scores at hospital discharge or 30 days after OHCA in patients who were randomized to endotracheal intubation versus supraglottic device to see if supraglottic devices were superior.


Between June 2015 and August 2017, the investigators conducted a multicenter, cluster randomized clinical trial involving 4 different ambulance services in England. Paramedics were randomized to use endotracheal intubation or supraglottic airways. In order to be included in the study, patients were required to meet the following criteria: 1) known or believed age greater or equal to 18; 2) non-traumatic OHCA; 3) treated by paramedic involved in study who was either first or second paramedic on scene; 4) continued resuscitation by EMS personnel. Patients were excluded from the study if they were prisoners, previously involved in the trial, had been deemed to have inappropriate resuscitation, had an advanced airway that was placed by another healthcare professional prior to arrival of study paramedics and patients that were known to be involved in other randomized control trials. The primary outcome of mRS score at discharge or 30 days after cardiac arrest was divided into favorable outcome (mRS score 0-3) or poor outcome (mRS score 4-6).

Key Results:

A total of 9.296 patients were enrolled in the trial, of which 4,886 patients were randomized to supraglottic airway versus 4410 were randomized to endotracheal intubation.  The investigators presented the following important key findings:

·       Favorable neurologic outcome [ mRS score (0-3)] at 30 days or hospital discharge (whichever came first): 6.4% (311/4882) in the supraglottic airway group versus 6.8% (300/4407) in the endotracheal intubation group (adjusted risk difference -0.6%; 95% CI -1.6%-0.4%)

·       In the subgroup analysis of 7576 patients who received advanced airway management (not intention-to-treat), more patients in the supraglottic airway device group had a favorable neurologic outcome (3.9%) vs. the tracheal intubation group (2.6%); risk difference, 2.1%; 95% CI, 1.2 – 2.9%

·       Successful initial ventilation: 87.4% (4255/4868) in the supraglottic airway group versus 79.0% (3473/4397) in the endotracheal intubation group (adjusted risk difference 8.3%; 95%CI 6.3% to 10.2%).

·       Rates of aspiration and regurgitation were not found to be different between the groups



Among patients with OHCA, advanced airway management with a supraglottic device was not associated with a favorable neurological outcome at 30 days compared to endotracheal intubation.

What This Means for EMS:

While the results of this study clearly indicated that advanced airway management with a supraglottic device was not associated with improvement in patient centered outcomes (in this case, neurological function), these devices were still associated with more successful initial ventilation without an increase in secondary complications such as aspiration/regurgitation. Furthermore, given the ease of use, less number of attempts required to obtain proficiency from a standpoint of training, and widespread availability, supraglottic devices are feasible intervention to provide airway support for patients with OHCA. Unlike endotracheal intubation which can be challenging to perform in the field with active chest compressions, supraglottic devices are easier to use in terms of temporary airway management and allow for the focus to be shifted towards measures that improve outcomes including high quality CPR and early defibrillation.

Article Bites Summary by Al Lulla, @al_lulla, Article Bites Editor

Article Bites #13: How Often Do They Get More Than One? Naloxone Redosing in the Age of the Opioid Epidemic

Klebacher R, Harris MI, Ariyaprakai N, et al. Incidence of Naloxone Redosing in the Age of the New Opioid Epidemic. Prehosp Emerg Care. 2017;21(6):682-687.

Background & Objectives:

The surging opioid epidemic has largely been combated with the use of intravenous and intramuscular naloxone administration. More recently, intranasal naloxone has been shown to be easily administered by not only EMS providers, but also law enforcement and family members to help reverse potentially fatal overdoses. Recently, mixed overdoses and ingestions with far more potent agents (such as carfentanyl) are on the rise, necessitating repeat naloxone dosing. The primary objective of this study was to determine the incidence of repeat naloxone administration for patients with suspected opioid overdose. The secondary endpoint was a more detailed descriptive and statistical analysis evaluating the precise characteristics associated with individuals who required repeat naloxone dosing.


The investigators conducted a retrospective chart review of the electronic health record of the largest EMS service in New Jersey. Charts were searched for the presence of naloxone administration and other key words including “drug overdose”, “poisoning” and “unresponsive”. Charts were examined between April 2014 and June 2016. In order to be included in the study, patients had to be over the age of 17 years and administered an initial dose of 2mg of intranasal naloxone. Initial naloxone administration was performed by law enforcement or a BLS unit per New Jersey state regulations. Subsequent doses of naloxone were administered by ALS units.  Resolution or “response” to therapy was defined as GCS of 15. In addition, demographic data was extracted from each patient encounter. 


Key Results:

In total, 2,166 patients received naloxone for suspected opioid overdose during the study period) April 2014 to June 2016). The key results from the study were as follows:

  • 1,971 of 2,166 (91%) of patients had reversal of overdose symptoms after a single dose of naloxone administered by law enforcement or BLS units 

  • 195 of 2,166 patients (9%) required a second dose of naloxone by an ALS unit given failure to respond after the initial dose

  • 53 of 2,166 patients (2.4%) required a third dose of naloxone by an ALS unit

  • Patients who required a second dose of naloxone had a mean GCS of 5.3 (standard deviation of 3.7). The mean respiratory rate was 10.4 breaths per minute with a mean oxygen saturation of 86.8%. 

  • Patients who required a third dose of naloxone had similar mean GCS scores (4.9) and oxygen saturations (86.4%). Two-thirds of the 53 patients who received a third dose of naloxone improved to a GCS of 15, suggesting that the remaining 1/3 patients may have had an alternative diagnosis for their altered mental status.


  • Among patients with suspected opioid overdose treated with intranasal naloxone by first responders or ALS units, 91% of patients had complete reversal of symptoms after a single dose of naloxone, with 9% requiring repeat dosing.

  • Naloxone is overall very effective at reversing symptoms of opioid overdose after a single dose

What this means for EMS:

With the rising incidence of mixed ingestions, more potent opioids such as carfentanyl, EMS providers are faced with more complexities in the management of opioid overdose. This study suggests that, in addition to basic support of ventilations, naloxone is still the mainstay of management in these patients, and highly effective at reversing overdose symptoms. Furthermore, this study suggests that in the majority of cases, first responders including law enforcement, and BLS units may be able to safely manage opioid overdose without the need for ALS units. This may improve resource utilization in EMS systems that are already stretched very thin. 

Article Summary by Al Lulla, MD (@al_lulla)

Article Bites #12: The Profile of Wounding in Civilian Public Mass Shooting Fatalities. 

Article: Smith ER, Shapiro G, Sarani B. The profile of wounding in civilian public mass shooting fatalities. J Trauma Acute Care Surg. 2016;81(1):86-92.

Background & Objectives:

Civilian mass shootings are unfortunately on the rise and afflict the lives of many individuals and their families. Given the rising incidence and severity of these events, there has been much in the way of public initiatives at improving morbidity and mortality in individuals who have been critically wounded. Much of the prior emphasis on management of these patients in the prehospital environment has focused on external hemorrhage control with widespread education on use of tourniquets. The strong focus on civilian management of exsanguinating extremity hemorrhage during mass shootings is largely based on the blast injury patterns identified during the US operations in Iraq and Afghanistan which suggest that between 52% and 64% of injuries in combat are to the extremities. Whether these lessons translate to civilian mass shootings is unclear. The overall purpose of this paper was to precisely identify the anatomic wounding pattern, fatal wounds and incidence of potentially survival wounds in civilian mass shooting incidents. 


The investigators conducted a retrospective study evaluating autopsy reports performed by medical examiners or coroners in 12 different mass shooting events. The investigators utilized the term “mass shooting” as defined by the FBI to mean:

  1. An incident occurring in a public space with 4 or more deaths (not including the shooter);

  2. Gunmen who select victims at random

  3. Violence without means to an end (i.e. not associated with robbery

Using reports made available by the New York Police Department and the FBI that provide detailed descriptions of civilian mass shootings dating back to 1966, the investigators identified 78 events that met the above definition for mass shooting events. 56 events that met the above definition had medical examiners or coroners that could be contacted. If the medical examiner or coroner was not listed or they could be not be contacted, the mass shooting event was eliminated from analysis. Request for official autopsy reports were sent to the respective examiners/coroners. Based on these reports, data was compiled regarding body site of wound, type of injury, probable site of fatal injury and whether wounds were potentially survivable. 

Key Results:

In total, based on responses from medical examiners, a total of 12 mass public shooting events were analyzed in the study. A total of 139 fatalities with 371 total wounds were examined by the investigators. The key results from the study were as follows:

  • There was an average of 2.7 wounds associated within the group of fatalities

  • The case fatality rate for civilian mass shootings was 44.6% (compared to approximately 10% during Operation Iraqi Freedom and Operation Enduring Freedom as reported in other studies). 

  • 58% of all victims (with fatal and non-fatal wounds) had at least one wound to head or chest/upper back

  • 20% (28/139) of all wounds were to the extremity, of which none were deemed to be fatal

  • 77% of all fatal wounds were identified in the head or chest/upper back. 

  • In total, only 9 of the 125 fatalities or roughly 7% (14 excluded given absence of autopsy data) were determined to be potentially survivable 

  • The most common survivable injury was a wound to the chest (89% of all survivable injuries) without obvious evidence of vascular or cardiac injury

  • There was 100% agreement between the reviewers of the study regarding potential survivability of injuries



  • Only 7% of victims in civilian mass shootings had a potentially survivable wound. No fatalities likely occurred secondary to exsanguination from extremity hemorrhage

  • The majority of wounds in civilian mass shootings occur primarily in the head, chest/upper back compared to combat environments where the majority of wounds occur in the extremities. 

  • The case fatality rate for civilian mass shootings compared to military data was much higher, and associated with lower number of potentially survivable injuries 

What this means for EMS:

While our nation faces a crisis with the issue of gun violence at the forefront of public discourse, regardless of what stance one may take on this issue, one thing remains abundantly clear: EMS providers are front and center when it comes to management of victims of mass shootings in the field. Historically, much of the focus on managing victims of mass shootings has been based on Tactical Combat Casualty Care (TCCC) guidelines based on the US military conflicts on the battlefields of Iraq and Afghanistan. These guidelines are largely predicated on the management of exsanguinating extremity hemorrhage with the use of tourniquets. This study despite all its limitations including retrospective design, missing data, and possibility of miscategorization of survivable and non survivable injuries, calls into question the applicability of these findings to the civilian arena where body armor is not worn. Based on the results of this study, EMS providers on the front lines who bravely care for victims of civilian mass shootings may encounter patients with wounding patterns that differ significantly compared to those seen in combat. While there is no question the importance of training and implementation of easy interventions such as tourniquets for the management of extremity hemorrhage, perhaps EMS providers must have a broader implementation of other treatment strategies that more accurately reflect the injury profile seen in civilian mass shootings, such as penetrating chest trauma. The authors of the present study carried out a more recent analysis looking at the victims of the Pulse nightclub shooting in Orlando, FL. The findings of this newer study which examined this single event (versus the 12 events in the examined in the present study) identified a disproportionately higher rate of individuals with extremity wounds (90% versus 20%). In this newer study, 4 patients were determined to have preventable death secondary to extremity hemorrhage (or in this case, junctional hemorrhage in the axilla). These patients who died did not have any evidence of tourniquet application, further emphasizing the point that despite the overall low incidence of death from extremity hemorrhage in mass shootings, it remains a quick and easy intervention that has the potential to save lives. The authors further concluded that in the Pulse nightclub shooting, similar to the 12 prior incidents, the majority of fatalities were again secondary to torso injuries highlighting the need for other interventions such as decompression of tension pneumothorax, basic airway management and management of hypothermia, which likely play a critical role in improving the dismal survival rates associated with civilian mass shootings. 


  1. Smith ER, Shapiro G, Sarani B. Fatal Wounding Pattern and Causes of Potentially Preventable Death Following the Pulse Night Club Shooting Event. Prehosp Emerg Care. 2018;22(6):662-668. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29693490

Summary by Article Bites Editor, Al Lulla MD (@al_lulla)

Article Bites #11: Measuring the Impact of a Telehealth Program on Ambulance Transports

Article Reviewed:

Champagne-langabeer T, Langabeer JR, Roberts KE, et al. Telehealth Impact on Primary Care Related Ambulance Transports. Prehosp Emerg Care. 2019;:1-6. [PMID: 30626250]

Background & Objectives:

Prior studies have confirmed what is known by many of those who work in EMS: a high proportion of patients that are transported have non-emergent conditions. Several studies have demonstrated that between 33 and 50% of all ambulance transports are for non-emergent causes. These transports often times result in signifiant resource utilization from EMS systems that are stretched very thin.  Furthermore, these transports may often be linked with ED overcrowding problems and increased healthcare costs. The role of telehealth has already been shown to be a cost effective and beneficial approach to many aspects of healthcare, including tele-ICUs and within EMS as part of trauma, stroke and cardiovascular care. The primary objective of this study was to investigate the impact of a large-scale telehealth program that utilizes non-ambulance based transportation (i.e. taxi) and paramedic triage of non-urgent complaints on overall EMS transports.


The investigators conducted an observational study from January 2015 to December 2017 for patients triaged by the Emergency Telehealth and Navigation Program (ETHAN) program developed by the Houston Fire Department. According to the study protocol, EMTs and paramedics were tasked with enrolling patients with non-life threatening conditions or mild illnesses. To be formally included in the study, the following criteria needed to be met:

  1. full history and physical exam with no obvious emergency

  2. age >3 months

  3. English speaking

  4. Normal vital signs; afebrile if chronically ill or over 65 years of age

  5. ability to care for self

  6. ability to be transported in a passenger vehicle. 

Patients who did not meet all inclusion criteria or who had other high risk features of their presentation suggestive of an emergency condition were excluded from the analysis. For those who qualified for the study, enrollees were connected via tablet to a board certified emergency physician who determined if the patient could be referred for follow-up with a primary care facility via versus requiring transport via ambulance. The primary variable that was studied was whether patients were transported by ambulance. Patients who were not transported via ambulance were offered transport to the ED or a primary care facility via taxi. 

Key Results:

During the study period, the investigators enrolled 15,067 patients in the telehealth program (equivalent to 2% of the overall EMS volume during this period). The key results from the study were as follows:

  • 11.2% of patients in the telehealth program were transported by ambulance

  • 75.6% of patients were transported by taxi instead of ambulance (5% of these patients were transported to a clinic instead of the ED)

  • 13.2% of patients transported themselves or were not transported at all

  • Patients were more likely to be transported by ambulance in the telehealth program if the chief complaint was abdominal pain (19.6%), low-risk chest pain (8.3%), shortness of breath (5.2%), or dizziness (3.7%)



  • Over the course of the study period, a telehealth program to identify patients with non-emergent conditions was successful in helping avoid unnecessary ambulance transports

What this means for EMS:

EMS agencies are faced with increased demand of services by the public with decreased available resources and higher costs. Telehealth in the prehospital setting is a novel approach to identify patients that may be suitable for transport via taxi and allow for EMS units to stay in service and serve other patients who present with other time critical conditions. This study did not show a significant decrease in the number of patients that were ultimately transported to the ED (only 2% of overall call volume participated & the majority of patients were still transported to the ED via taxi) and did not provide patient outcome data regarding accuracy of triage as non-emergent. However, it does demonstrate that a telehealth program is feasible within a large EMS system and highlights a promising avenue towards matching healthcare resources with patient needs and thus represents an important advancement in the field of EMS medicine.

Article Review by EMS MEd Article Bites Editor, Al Lulla MD (@al_lulla)

Article Bites #10: Delivering Right Care and Transporting to the Right Place: Medical clearance of Psychiatric Emergencies in the Field

Article: Trivedi TK, Glenn M, Hern G, Schriger DL, Sporer KA. Emergency Medical Services Use Among Patients Receiving Involuntary Psychiatric Holds and the Safety of an Out-of-Hospital Screening Protocol to "Medically Clear" Psychiatric Emergencies in the Field, 2011 to 2016. Ann Emerg Med. 2019;73(1):42-51.

Background & Objectives:

Due to a nationwide shortage of inpatient psychiatric beds, patients with psychiatric emergencies often spend long periods of time waiting in the ED for placement for psychiatric care. These long wait times are associated with more ED overcrowding, increased costs, and unfortunately sometimes inhumane conditions for patients and increased stress for staff. The vast majority of patients with involuntary psychiatric holds are brought to the ED by EMS, usually for medical clearance and evaluation for other possible non-psychiatric causes of the patient’s presentation. This study investigated the role of an EMS field protocol to allow EMS to bypass EDs and transport patients directly to a psychiatric facility. 


The investigators conducted a retrospective review of all EMS transports in Alameda County, CA between November 1, 2011 to November 1, 2016, focusing particularly on patients receiving involuntary psychiatric holds. To assess for patients who received involuntary holds, the investigators evaluated the medical priority dispatch system code, primary impression, secondary impression and medical narrative as documented by EMS providers. According to the Alameda County EMS Agency protocol (see further reading below) patients with isolated psychiatric presentations can be transported directly to a stand alone psychiatric facility provided protocol criteria is met. Two primary outcomes were examined. First, the investigators compared “involuntary hold patients” with those patients who never received an involuntary hold to identify what specific characteristics were associated with patients receiving involuntary hold status. The second outcome that was evaluated was the safety of an EMS field protocol to screen patients for direct transport to a psychiatric facility and bypass of the ED. This measure was defined by retransport of a patient to the ED within 12 hours of transport to the psychiatric facility (AKA “failed diversion”).

Key Results:

During the study period, the investigators identified 541,731 total EMS transports (257,725 unique transports). Of the total transports, 10% (n=53,887) were for involuntary holds. The key results from the study were as follows

  • 41% (n=22,074) of transports for involuntary hold patients met protocol criteria for ED diversion and direct transport to stand alone psychiatric facility

  • Of patients who were transported to stand alone psychiatric facility, 0.3% (n=60) failed diversion and required retransport to ED within 12 hours

  • Involuntary hold patients were found to have significantly more total EMS use (24% of all encounters; n=128,003) compared to patients that never received hold status. They were also more likely to be younger, men, and have uninsured status

  • Of the patients requiring retransport within 12 hours, 54 of 60 of those patients developed new symptoms on arrival to the facility which did not manifest with their initial presentation to EMS. Reasons for retransport included traumatic injury (n=5), previously unrecognized or unreported symptom (n=13), seizure (n=8), excessive sedation (n=10), staff request for medical clearance of asymptomatic patient (n=7) new mental status change (n=5) or patient discharge from psychiatric service and self referral to EMS (n=5)



  • Over the course of a 5 year period, an EMS field protocol to screen psychiatric involuntary hold patients for direct transport to a stand alone psychiatric facility performed safely, with only 0.3% of transported patients requiring retransport to an ED within 12 hours

  • Involuntary hold patients were usually younger and often uninsured. In addition, they had significantly higher overall EMS utilization

What this means for EMS:

This study demonstrates that implementation of an EMS field protocol can allow for safe diversion from ED directly to a psychiatric facility. The implementation of such protocol in EMS systems would likely have a significant impact on ED overcrowding and length of stay. This study highlights two important points: 1) The role of EMS with respect to hospital operations, ED operations and the health care system as a whole cannot be overstated. EMS systems nationwide may be able to build upon the lessons from Alameda County and help reduce ED overcrowding concerns as well as more rapidly direct patients to the psychiatric care they need. 2) EMS utilization by patients with psychiatric illness is significant, with roughly one-quarter of all transports in Alameda County being for “involuntary holds” during the 5 year study period. This further re-inforces the importance of both federal and local resource allocation for psychiatric illness. 

Further Reading: 

Alameda County EMS involuntary hold protocol:


Review and Infographic by Article Bites Editor, Al Lulla MD (@al_lulla)

Article Bites #9: The Emergency within EMS - Risk of Suicide in EMS Compared to the General Public

Death by Suicide — The EMS Profession Compared to the General Public

Vigil NH, Grant AR, Perez O, et al. Death by Suicide-The EMS Profession Compared to the General Public. Prehosp Emerg Care. 2018;:1-6.[PMID: 30136908]


Background & Objectives:

 Suicide is a public health crisis with an estimate 45,000 individuals dying from suicide annually. Certain professions, including law enforcement and EMS are exposed to high degrees of workplace stress, therefore it is hypothesized that these individuals are more predisposed to conditions including anxiety, depression and suicidal ideation and behaviors. Survey data examined by the National Association of Emergency Medical Technicians (NAEMT) has indicated that there is very high occurrence of suicidal ideation within the EMS community. Despite this important information, the relationship between suicidal ideation and suicide attempt with the completion of suicide in EMS providers has not been well studied. The authors of this study aimed to assess the odds of death by suicide completion in EMTs compared to non-EMTs.  


The investigators conducted a retrospective case-control study that analyzed the electronic death registry in Arizona from January 2009 to December 2015. Only adults greater than or equal to the age of 18 were included in the analysis. Multiple variables from the death registry were examined including age gender, race, ethnicity, and most importantly for the purposes of this study: cause of death and occupation. With respect to occupation, the term "EMT" was categorized as all individuals who had EMT certification, including firefighters, EMTs and paramedics. A logistic regression model was implemented to calculate the mortality odds ratio (MOR) of suicide between EMTs (exposed group) and non-EMTs (non-exposed group). 


Key Results:

In total, 350,998 adults were analyzed who died during the above time period. The key results from the study were as follows:

· There were 1,205 EMT deaths during the study period

o   63 (5.2%) were attributed to suicide. This is compared to the non-EMT group of which 2.2% of deaths were due to suicide. 

· MOR for EMTs versus non-EMTs was 2.45; [95% CI (1.88-3.13)]

· Adjusted MOR for EMTs versus non-EMTs was 1.29; [95% CI (1.06-1.82)] adjusted for gender, age, race and ethnicity 


· The most common mechanisms of suicide in the EMT group was firearm (67%), however there was no significant difference between death by firearm in the EMT cohort versus the non-EMT cohort. 



· In the Arizona electronic death registry, there were higher odds for death by suicide in EMTs compared to the general public. 


What this means for EMS:

EMS providers are faced with significant workplace stressors. Whether it’s traumatic calls, poor sleep quality, poor compensation, long hours, or overall low job satisfaction, EMS remains one of the most challenging professions. These aspects of the EMS profession, unfortunately, contribute to a host of mental health issues including depression, anxiety, PTSD, all of which predispose individuals to developing suicidal ideation and behaviors. The time to act is now. The results of this study are extremely compelling and must serve as the impetus for change within the profession. Further studies that precisely characterize the risk factors that place EMS providers at higher risk than the general public should be examined as well. Despite this, the findings from this research still demonstrate the need for greater EMS education regarding the symptoms and warning signs of suicidal behavior, the importance of adequate resources for counseling and mental health, and improved work conditions to protect those individuals who protect our communities and our patients. 

Article Reviewed by Article Bites Editor Al Lulla, MD.

Article Bites #8: Reconsidering Priorities of care: epinephrine in out of hospital cardiac arrest

A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest

Perkins GD, Ji C, Deakin CD, et al. A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. N Engl J Med. 2018. [PMID: 30021076]

Background & Objectives:

Other than early CPR and defibrillation, there are few measures that have been shown to improve outcomes for out-of-hospital cardiac arrest (OHCA). Despite this, epinephrine has been at the crux of ACLS management of patients with OHCA given the thought that it can cause peripheral vasoconstriction, increased beta adrenergic activity and augment coronary blood flow. In turn, epinephrine increase chances of return of spontaneous circulation (ROSC). While higher rates of ROSC have been confirmed in prior studies on epinephrine, unfortunately most of what we know about epinephrine suggests that it’s administration may not improve the most important clinical outcome - neurologically intact survival. The PARAMEDIC2 trial (Prehospital Assessment of the Role of Adrenaline: Measuring the Effectiveness of Drug Administration in Cardiac Arrest) was performed to assess whether epinephrine was beneficial or harmful as demonstrated by the primary outcome of 30 day survival. 


The investigators conducted a multi agency (5 ambulance services), randomized, double-blind, placebo controlled trial in the United Kingdom from December 2014 to October 2017 in adult patients who sustained OHCA for which ACLS was provided by paramedics. Patients were excluded from the trial if they were pregnant, less than 16 years of age, had cardiac arrest secondary to anaphylaxis or asthma, or if they had administration of epinephrine prior to the arrival of EMS personnel. If initial resuscitation measures (CPR and defibrillation) were unsuccessful, patients were randomized to the intervention arm (1mg epinephrine q3-5 mins in accordance with ACLS protocols) or the control arm (normal saline placebo). As stated above, the primary outcome of the trial was 30 day survival. Secondary outcomes that were examined included rate of survival until hospital admission, length of hospital stay and ICU stay, rates of survival at hospital discharge and at 3 months, neurological outcomes at hospital discharge and at 3 months. Favorable neurological outcome was defined as modified Ranking score of 3 or less. 

Key Results:

In total, 8014 patients with OHCA were enrolled in the study over the 3 year period of which 4015 patients were in the intervention arm (epinephrine) compared to 3999 patients in the placebo arm. Both groups were well matched in terms of baseline patient characteristics.The key results from the trial were as follows:

  • 30 day survival: 3.2% in epinephrine group vs 2.4% in placebo group (OR 1.39; 95% CI 1.06-1.82, p=0.02).

  • Favorable neurological survival at 3 months (modified Rankin score 3 or less): 2.1% in epinephrine group vs. 1.6% in placebo group (OR  1.31; 95% CI 0.94-1.82.

  • Severe neurological impairment (modified Rankin score 4 or 5): 31% in epinephrine group vs. 17.8% in placebo group

  • ROSC during prehospital resuscitation: 36.3% in epinephrine group vs. 11.7% in placebo group

Takeaways:In this multi-agency, prospective, double blinded randomized placebo controlled trial, administration of epinephrine for OHCA was associated with a statistically significant higher 30 day rate of survival compared to placebo, but no difference in neurologically-intact survival.

Epinephrine Group (2).jpg

What this means for EMS:This study is the largest randomized controlled trial performed to date studying the impact of epinephrine administration on survival and neurological outcomes for OHCA. While administration of epinephrine has long been the pharmacological mainstay of prehospital (as well as in-hospital) management of OHCA, this trial calls into question its influence on patient centered outcomes (i.e. neurological intact survival). While this paper will surely be at the center of debate in the upcoming years within EMS circles around the world, one thing remains abundantly clear at this point: good quality BLS Care in the form high quality CPR and early defibrillation have the greatest impact on neurologically intact survival and should be the primary focus of resuscitation for cardiac arrest.


Article Bites #7: Should Air Medical Transport administer plasma to trauma patients at risk for hemorrhagic shock?

Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock

Sperry JL, Guyette FX, Brown JB, et al. Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock. N Engl J Med. 2018;379(4):315-326. [PMID: 30044935]

Background & Objectives:

Hemorrhagic shock remains the most significant cause of mortality in trauma patients. In particular, coagulopathy is a significant contributor to death in this patient population and has been a focus of what is termed “damage-control resuscitation” in both civilian and battlefield arenas. Currently, there is a stronger push for resuscitation with blood-components including platelets and packed red cells in favor over crystalloid based resuscitation strategies. The premise of early damage control resuscitation in the pre-hospital environment is predicated on intervening at the point of injury and mitigating downstream complications including coagulopathy and irreversible hemorrhagic shock. Plasma administration as part of damage control resuscitation is thought directly address coagulopathy and improve chances for survival. This trial, termed the “Prehospital Air Medical Plasma (PAMPer)” trial sought to investigate the efficacy and safety of prehospital plasma administration in severely injured trauma patients. The primary outcome was the impact of prehospital plasma administration on 30 day mortality. 


The investigators conducted a phase 3 multi-center cluster-randomized trial involving trauma  patients (blunt or penetrating) who were deemed to be at risk for hemorrhagic shock during air medical transport. Individual air medical bases were randomized to give plasma vs standard resuscitation in 1 month blocks. The intervention arm included patients who received 2 units of universal donor thawed plasma. The comparison group received standard of care resuscitation (crystalloid based resuscitation). Patients were deemed to be “at risk” for hemorrhagic shock were enrolled in the trial if they had at least one episode of hypotension (defined as systolic BP <90 mm Hg) and tachycardia (defined as HR >108 BPM) or if they had severe hypotension (defined as SBP <70 mm Hg) at any point in the prehospital phase of care. There were several exclusion criteria some of which included patients older than age 90 or younger than age 18, individuals who were pregnant, had traumatic cardiac arrest lasting longer than 5 minutes, penetrating brain injury, or refusal by family member to participate in the trial or if the patient was wearing an “opt-out” bracelet reflecting their wish not to participate in the trial, among others. 

Key Results:

There were 27 air medical transport bases that were recruited for the study that transported patients to 9 different level 1 trauma centers across the United States between 2014 to 2017. In total, 7,275 patients were transported during the study period, of which 501 patients qualified for the study. Of these patients, 230 received plasma and 271 received standard care resuscitation. Average prehospital time was 40 minutes (95% CI 33-51) and 42 minutes (95% CI 34 to 53) in the plasma and saline treated groups respectively. The key findings were as follows:

  • Mortality at 30 days was significantly lower in the plasma group (23.2%) versus standard group (33.0%)

  • Absolute reduction was 9.8% in the plasma group (95% CI 1.0 to 18.6%; P=0.03). 

  • Median INR was lower in plasma group compared to standard group (1.2 vs 1.3; p<0.001)

  • No statistically significant difference was found in outcomes with respect to other variables including multi organ failure, acute lung injury/ARDS, or transfusion-related reactions

  • Number needed to treat (NNT) was 10. 



  • In this prospective trial administration of plasma in the prehospital aeromedical transport setting was associated with decreased 30 day mortality in trauma patients at risk for hemorrhagic shock.

What this means for EMS:

In 2015, the PROPPR trial demonstrated improved outcomes in trauma patients receiving blood products (packed red cells, platelets, plasma) compared to crystalloid resuscitation. Little research has been done on the role of plasma administration at the point of injury in the prehospital setting. This study was one of the first to show that rapid prehospital administration of plasma products is associated with improved 30 day mortality. As stated in Article Bite #4, transfusion of blood products in the prehospital setting is associated with many logistical roadblocks, including but not limited to refrigeration, coordination with blood banks, and issues pertaining to wastage of products with a short shelf life, are all important considerations prior to routine implementation of this intervention. Given the traditional model of prehospital trauma care has focused on rapid transfer to a trauma center for definitive management, prehospital administration of plasma is a potential intervention that may lead to improved patient outcomes in some systems where distance to trauma center leads to extended prehospital times*.

Article summary and figure by Article Bites Editor Al Lulla, MD

* The COMBAT trial, which evaluated prehospital plasma transfusion for patients with signs of hemorrhagic shock within an urban system, did not find similar benefit.

Article Bites #6: Mac vs. Miller - A Retrospective review of Intubation Success


by Aaron Farney, MD


Alter, S. M., Haim, E. D., Sullivan, A. H., & Clayton, L. M. (2018). Intubation of prehospital patients with curved laryngoscope blade is more successful than with straight blade. The American journal of emergency medicine.


There are two direct laryngoscope blades available to EMS: the curved Macintosh and the straight Miller.  Most providers learn to operate both blades, but tend to gravitate towards one based on personal and/or institutional preference.  Existing literature suggests the straight blade allows for better visualization, but perhaps intubation is easier with a curved blade.  However, there are no existing studies comparing these blades in the prehospital setting.  The aim of this study is to compare intubation success with a Macintosh blade versus a Miller blade as performed during pre-hospital endotracheal intubation (ETI) by paramedics.

Methods: This was a retrospective chart review of patients who underwent prehospital ETI from 2007 – 2016 by a single hospital-based suburban EMS service in/near Boca Raton, FL. This system had a 20K EMS volume, double ALS ambulances, 2-tiered system. Intubation attempt was defined as blade passing incisors. Intubation success was defined as confirmation of oxygenation & ventilation following ETI.

Outcomes and results

  • 2,299 patients had ETI attempted

  • 1,865 attempted with curved blade only (81%)

  • 367 attempted with straight blade only (16%)

  • 67 attempted using both blades (3% - added to both groups above)

  • Both groups were similar in age, weight, and gender

Conclusions: Both first pass success rates and overall intubation success rates for paramedics were significantly higher when Mac blades were used.



In this retrospective study,  first pass success rates and overall intubation success rates for paramedics were higher when Macintosh blades were used.  The difference of 13-15% is expected to be clinically significant. Other process measures such as perintubation hypoxia were not measured. The results of this study demonstrate correlation, not necessarily causation and are subject to confounding variables.   For example, the training backgrounds, in particular experience with different blade times, are unknown. However, this is a thought provoking study from the education and training perspective.  Should we be stressing training with curved blades or should we focus efforts to improve training with Miller blades or versatility in psychomotor skills?


Article Bites #5: Pediatric Intubation - What's the first pass success rate in a physician-staffed helicopter retrieval service?

Analysis of Out-of-Hospital Pediatric Intubation by an Australian Helicopter Emergency Medical Service. 

Burns BJ, Watterson JB, Ware S, Regan L, Reid C. Analysis of Out-of-Hospital Pediatric Intubation by an Australian Helicopter Emergency Medical Service. Ann Emerg Med. 2017;70(6):773-782.e4. [PMID: 28460858]

Background & Objectives:

Adequate establishment and maintenance of a patent airway is one of the hallmarks of resuscitation. Pediatric intubation poses particular challenges, most notably lack of provider experience. It is estimated that first-pass success ranges from 66% to 85%. Prior studies have demonstrated no significant improvement in pediatric outcomes with prehospital intubation.  The intubation success rate in this study was only 57%.  [1]  Despite the difficulties associated with pediatric intubation, it remains within the scope of practice in the prehospital setting in some EMS services. The primary goal of this study was to report first-look success rate in pediatric advanced airway management in a physician-led adult out-of-hospital helicopter retrieval service. The secondary goal was to evaluate for potential complications of airway management as well as success by operator type, patient age and type of intubation.


The investigators conducted a retrospective study evaluating patients who were treated by the Greater Sydney Area Helicopter Emergency Medical Service in Australia. This helicopter EMS service (HEMS) is comprised of a 2-person medical team with a physician and a paramedic. Physicians were usually board certified in emergency medicine or anesthesiology or residents with at least 5 years of experience. Paramedics were critical care paramedics with 10 years of experience and additional training with out of hospital care and retrieval medicine. The investigators evaluated an analysis of all out of hospital and interhospital pediatric intubations between January 2010 and April 2015. The only inclusion criteria was that the patient be younger than 16 years of age. Patients were intubated at the discretion of the team, with rapid sequence intubation (RSI) versus cold intubation (most frequently for cardiac arrest). The measures that were reported included critical timings (i.e. time to intubation), demographics, provider background, number of intubation attempts and complications. 

Key Results:


In total there were 10,856 patients treated during the study period, of which 497 (4.6%) were pediatric patients. Of these patients, 82 (16.5%) were intubated by this particular HEMS service. The key findings were as follows:

  • First look success rate: 91% (75/82; 95% CI 83 to 97%). The overall success rate was 100%. 
  • 80% of patients were successfully intubated within 1 to 2 minutes after induction
    • 69/82 (84%) were rapid sequence inductions (RSI)
    • Ketamine was the most commonly used induction agent, utilized in 63/69 patients (91%) undergoing RSI
  • The most common indications for intubation included trauma (83%), head injury (56%), combative/agitated patient (29%). 
  • Median time to intubation was 25 minutes (defined as time from HEMS arrival to intubation)
  • Complication rate including hypotension, bradycardia and desaturation was 14%
  • Difficult airway indicators were present in 77% of patients that were intubated by this service


  • In this retrospective series of pediatric intubations in the prehospital setting by a physician-lead helicopter service, first pass success was 91%. Overall success rate was 100% with only 9% of patients requiring multiple attempts). 

What this means for EMS:

The role of intubation in the field for pediatric patients is extremely controversial. Prior studies have demonstrated low rates of first pass success and overall lack of significant improvement in patient outcomes. This study showed an uncharacteristically high rate of first past success in the prehospital setting for pediatric patients. The investigators of this study attribute their high rate of success to a rigorous training program for providers in the field, frequent practice and checklists amongst other mandated practices. Overall, pediatric intubation in the field is a relatively rare occurrence with limited “on-the-job” training experience, which may be what has historically contributed to its unsuccessful implementation in the field. This study highlights the importance of adequate training and psychomotor mastery to performance of critical skills, particularly those that are rarely performed.  It did not evaluate the effect on clinical outcomes. 


1. Gausche, M., Lewis, R. J., Stratton, S. J., Haynes, B. E., Gunter, C. S., Goodrich, S. M., ... & Seidel, J. S. (2000). Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial. Jama283(6), 783-790.


Article Bites #4: Learning from the Military - Association between Prehospital Blood Product transfusion & survival for Combat Casualties



Association of Prehospital Blood Product Transfusion During Medical Evacuation of Combat Casualties in Afghanistan With Acute and 30-Day Survival

Shackelford SA, Del junco DJ, Powell-Dunford N, et al. Association of Prehospital Blood Product Transfusion During Medical Evacuation of Combat Casualties in Afghanistan With Acute and 30-Day Survival. JAMA. 2017;318(16):1581-1591. [PMID: 2906742]

Background & Objectives:

Given that hemorrhage is the leading cause of death in patients suffering from severe traumatic injuries, the utility of prehospital blood product transfusion has been a highly debated topic. Despite the important role of early transfusion in the management of hemorrhagic shock, the majority of published data at this time has shown inconclusive findings with regards to survival benefit from prehospital blood product transfusion, particularly within civilian trauma systems. Many of these studies suffered from significant flaws, and therefore, the verdict is still out on the role of prehospital transfusion. The purpose of this study was to address these deficiencies in the medical literature by studying the effect of prehospital transfusion within the context of the US military experience on MEDEVAC aircraft in Afghanistan. More specifically, the authors of this manuscript wanted to study the following question: Is prehospital blood product transfusion among military combat casualties associated with improved survival at 24 hours and at 30 days?


The investigators conducted a retrospective cohort study of US military combat casualties in Afghanistan between April 1, 2012 and August 7, 2015. Patients were recruited from the Department of Defense trauma registry, the prehospital trauma registry, and the Armed Forces Medical Examiner System Database. Inclusion in the study was predicated on the following criteria being met: 

1.     US military service member who survived until MEDEVAC rescue from point of injury AND

2.     At least 1 of the following criteria for prehospital transfusion for severe trauma 

· 1 or more traumatic limb amputations with at least 1 amputation located above the knee or elbow OR 

· Hemorrhagic shock defined by systolic blood pressure <90 mmHg or heart rate >120 beats per minute 

The interventions that were examined were 1) initiation of prehospital transfusion (red blood cells and/or plasma) and 2) minutes from MEDEVAC rescue to initiation of transfusion regardless of setting (i.e. in the field vs surgical hospital). As stated earlier, the key outcomes that were examined were survival at 24 hours and at 30 days. Interestingly, the investigators compared individuals who received prehospital transfusion to nonrecipients of prehospital transfusion. These individuals were frequency matched based on 5 characteristics including mechanism of injury, prehospital shock, type and severity of traumatic limb amputation hemorrhagic torso injury assessed by Abbreviated Injury Scale (AIS) and finally severity of head injury assessed by AIS score. Using Cox regression analysis, further stratification was performed and adjusted for age, injury year, transport team, tourniquet use and time to MEDEVAC rescue. 

Key Results:

During the specified time frame of the study, there were 502 casualties who met inclusion criteria. 55 individuals received prehospital transfusion vs 447 individuals who did not receive transfusion. Of these individuals who did not receive transfusion, 345 were frequency matched to prehospital transfusion recipients based on the characteristics mentioned above. The key findings were as follows:

With respect to the entire study population:

· Within 24 hours of MEDEVAC rescue, 3/55 (5%) of prehospital transfusion recipients died compared to 85/447 (19%) of non-recipients (between group difference -14%; 95% CI -21% to -6%; p=0.01). 

· Within 30 days of MEDEVAC rescue, 6 prehospital transfusion recipients died (11%) compared to 102 non-recipients (23%) (between group difference -12%; 95% CI -21% to -2%; p=0.04)

With respect to matched study cohorts:

· Within 24 hours of MEDEVAC rescue, 3 (5%) prehospital transfusion recipients died compared 69 (20%) matched non-recipients (between group difference -15%; 95% CI -22% to -7%; p=0.007)

· Within 30 days of MEDEVAC rescue, 6 (11%) prehospital transfusion recipients died  compared to 78 (23%) matched non-recipients (Between group difference -12%; 95% CI -21% to -2%; p=0.05)

With respect to survival analysis:

· Among the 386 patients within the matched groups, adjusted hazard ratios were calculated. The investigators reported the adjusted hazard ratio for mortality to be 0.26 (95% CI 0.08 to 0.84; p=0.02) within the first 24 hours. Within the first 30 days, the adjusted hazard ratio for mortality was 0.39 (95% CI 0.16 to 0.92; p=0.03). 

With respect to time to first transfusion:

· The study revealed that time to initial transfusion was associated with reduced mortality within 24 hours only up to the first 15 minutes after MEDEVAC rescue (adjusted hazard ratio 0.17 95% CI 0.04-0.73; p = 0.02)


· For US military casualties in Afghanistan, prehospital blood transfusion was associated with a statistically significant improvement in survival at 24 hours and 30 days compared with a matched sample that received no prehospital transfusion. 

· Early prehospital transfusion was associated with improved mortality but only within the first 15 minutes of MEDEVAC rescue. 


What this means for EMS:

There is no question that civilian trauma care has been greatly influenced by lessons learned on the battlefield. While this study performed on MEDEVAC helicopters in Afghanistan supports the notion that improved mortality can be achieved with prehospital blood transfusion for hemorrhagic shock, the translation of these findings to EMS systems back home may be more challenging. For starters, the logistical implementation of prehospital blood transfusion would require massive utilization of precious resources. Refrigeration, coordination with blood banks and hospitals, and care as to avoid wasting of life saving blood products are few of the many obstacles to ubiquitous implementation of prehospital blood transfusion in the civilian EMS world. Furthermore, the advanced resuscitative capabilities of MEDEVAC aircraft may not always be readily available in civilian systems, which may have accounted for the improved mortality observed in the study. Overall, while the results from the study were extremely encouraging, more research needs to be done to evaluate the precise role of prehospital transfusion in civilian EMS settings. 


Article Bites #3: Does the Duration and Depth of Out-of-Hospital Hypotension affect mortality in TBI?


Outcomes related to traumatic brain injury are thought to be related to cerebral perfusion pressure (among other factors). Cerebral perfusion pressure is equal to mean arterial pressure minus the intracranial pressure. Hypotension decreases cerebral perfusion pressure to the brain and is associated with increased mortality in this patient population. This is of particular importance especially in the prehospital arena where prior research has demonstrated that hypotension is associated with increased mortality in patients with traumatic brain injury. However, there have been no studies to date have examined the relationship between both the depth and the duration of hypotension with  mortality in patients with traumatic brain injury. The investigators of this study sought to tackle this very issue.



The investigators conducted a retrospective observational study of patients with traumatic brain injury within the EPIC (Excellence in Prehospital Injury Care) database as part of the Arizona State Trauma Registry between January 2007 and March 2014. The primary outcome examined was survival to hospital discharge. Patients were determined to have traumatic brain injury based on trauma center diagnoses as a part of either isolated traumatic brain injury or multi system traumatic injury.  More specifically, participants were selected who met the classification for moderate or severe traumatic brain injury based on CDC guidelines, ICD-9 head region severity scores and Abbreviated Injury scores. Patients were excluded from the study if they were younger than 10 years of age, were involved in an interfacility transfer or had any systolic blood pressure greater than 200, or systolic blood pressure of 0 indicating traumatic arrest. Hypotension was defined as SBP <90 mmHg. To calculate the “dose” of hypotension, the investigators looked at the depth of hypotension integrated across exposure time (in minutes) AKA “area under the curve”. The integrated values from all hypotensive segments were added together to obtain a dose (in mmHg-minutes). The relationship between mortality and hypotension dose was examined by logistic regression analysis with adjustment for confounding factors.


Key Results:

A total of 16,711 transports for patients with traumatic brain injury were analyzed during the study period, of which 7,521 met inclusion criteria for the study. The key findings were as follows:

· 539 of 7,521 patients (7.2%) were hypotensive during transport

· Among patients with no hypotension (6,982 patients), mortality was 7.8% (95% CI 7.2 to 8.5%). This compared to patients who were hypotensive, where there was 33.4% (95% CI 29.4 to 37.6%) mortality

· Mortality increased in a linear relationship using a log2 hypotension dose and log odds of death (OR =1.19, 95% CI 1.14 to 1.25) per 2 fold increase in hypotension dose increase. In specific quartiles of hypotension dose, the following outcomes were established:

o   16.3% mortality with dose between 0.01 to 14.99 mmHg-minutes

o   28.1% mortality with dose between 15 to 49.99 mmHg-minutes

o   38.8% mortality with dose between 50-141.99 mmHg-minutes

o   50.4% mortality with dose greater than 142 mmHg-minutes



· A dose response exists between prehospital hypotension dosage and mortality. Each 2 fold increase in hypotension dose (depth of hypotension integrated over time) during prehospital transport is associated with a 19% increase in mortality


What this means for EMS:

Out-of-hospital hypotension for patients with traumatic brain injury is associated with worse patient outcomes, i.e. decreased survival to hospital discharge. While this study was observational and did not address whether treatment of hypotension improved survival or neurologically intact recovery, it did emphasize an important variable that may serve as the foundation for future EMS research and quality improvement initiatives regarding the management of traumatic brain injury in the field. Going forward, more accurate (and more frequent) acquisition of blood pressure measurements in the prehospital setting may prove to be invaluable in implementing future prehospital resuscitative strategies for patients with traumatic brain injury. 


Article Bites #2: Identifying factors associated with repeated transports of older adults


Background & Objectives:

Adults aged 65 and older make up a significant proportion of the population (estimated to be approximately 20% of the total US population by 2030). In addition, this subset of patients has disproportionate utilization of EDs as well as EMS services (estimated at 38% of EMS transports). Little is known regarding the precise characteristics of this population that is associated with higher utilization of EMS. The investigators of the study aimed to investigate the proportion of older adults receiving repeat transport within 30 days and to potentially identify characteristics that were associated with repeat use of EMS. 


The investigators conducted a retrospective analysis of EMS transports listed in the North Carolina Prehospital Medical Information Systems (PreMIS) database from 2010 to 2015. In particular, EMS encounters that were associated with 911 calls for adults aged 65 years or older that resulted in transport were examined. The primary outcome that was evaluated was repeated EMS transport within 30 days. Additional secondary outcomes that were examined included stratification of individuals by total number of EMS transports during the study period within 30 days. A multivariable logistic regression model was used to calculate adjusted odds ratios and 95% confidence intervals of repeated EMS transport within 30 days. 

Key Results:

A total of 1,719,998 transports for individuals aged 65 or greater were analyzed during the study period, of which 689,664 were for unique individuals. In this specific population, the key findings were as follows:

  • 17.7% (303,099 transports) had at least one repeated transport within 30 days
  • Odds of repeated transport within 30 days was higher in the following individuals: 

- Those from healthcare/residential facilities (OR 1.42 CI 1.38 to 1.47)

 - Black vs white (OR 1.29 95% CI 1.24 to 1.33)

 - Dispatch complaint of “sick person”, “fall”, “breathing problem”, “abdominal pain”, “diabetic problem”, “unknown person/person down”, “back pain”, “psychiatric problem”, “headache”

  • 15.6% of all repeated transports were related to falls 


  • Greater than 1 in 6 EMS transports of individuals greater than the age of 65 is followed by a repeated transport within 30 days. 
  • Individuals in healthcare/residential settings and blacks (versus whites) have increased odds of repeated transport within 30 days

What this means for EMS:

Repeat transport of elderly adults is associated with significant healthcare costs and utilization of limited resources both in the hospital and pre-hospital setting. Identification of specific variables that are associated with repeated transport may assist with the development of targeted strategies to both improve patient outcomes and simultaneously decrease the demand for EMS resources that are already stretched very thin. 


Article Bites #1: Bystander Efforts and 1-Year Outcomes in Out-of-Hospital Cardiac Arrest


Reference: Kragholm K, Wissenberg M, Mortensen RN, et al. Bystander Efforts and 1-Year Outcomes in Out-of-Hospital Cardiac Arrest. N Engl J Med. 2017;376(18):1737-1747. [PMID: 2846789]

Background & Objectives:

Bystander CPR and defibrillation has been associated with increased survival in patients with out-of-hospital cardiac arrest (OHCA). It is well studied that many patients who survive cardiac arrest have long term neurological deficits secondary to anoxic brain injury. Many of these patients require assistance with activities of daily living in the form of nursing home care. However, there is little known whether there is any improvement in functional outcomes for patients with OHCA in the setting of bystander CPR and defibrillation. The authors of this study hypothesized that bystander CPR in addition to use of an automated external defibrillator would potentially augment cerebral perfusion and reduce the extent of neurological insult by decreasing the amount of time to acquisition of ROSC. The authors sought to examine whether bystander CPR and bystander defibrillation would affect long term risk of anoxic brain damage or nursing home admission among 30 day survivors of OHCA over a 1 year period.  


Danish investigators evaluated all 30 day survivors for OHCA aged 18 and older who were listed in the Danish Cardiac Arrest Registry from 2001 to 2012. Using nationwide registries, 1 year risk of anoxic brain injury, nursing home admission and all cause mortality was examined. Survivors of cardiac arrest were divided into four groups: 1) no bystander resuscitation 2) bystander CPR but no bystander defibrillation 3) bystander debrillation (regardless of bystander CPR status) and 4) EMS witnessed cardiac arrest. In addition, temporal changes in bystander interventions were studied (i.e. outcomes in relationship to increasing rates of bystander interventions in Denmark over the study period). 

Key Results:

Of the 34,459 individuals eligible for the study, 2,855 patients were 30 day survivors of OHCA during the 2001-2012 study period. The key findings were as follows:

  • 10.5% of patients had anoxic brain injury or were admitted to a nursing home. 9.7% of patients died within 1 year.  
  • Percentage of 30 day survivors increased from 3.9% to 12.4% over the course of the study
  • Percentage of bystander CPR in OHCA unwitnessed by EMS (n=2084) increased from 66.7% to 80.6% (p<0.001) over the course of the study. Percentage of bystander defibrillation increased from 2.1% to 16.8% (p<0.001). In concert, the rate of brain damage or nursing home admission decreased from 10.0% to 7.6% (p<0.001). All cause mortality decreased from 18.0% to 7.9% (p=0.002). 
  • Bystander CPR was associated with lower risk of brain damage or nursing home admission compared to no bystander resuscitation (adjusted hazard ratio 0.62 95% CI 0.47-0.82). Similar findings were observed with bystander defibrillation compared to no bystander resuscitation (adjusted hazard ratio 0.45 95% CI 0.24-0.84) 


  • There is lower risk of anoxic brain damage, nursing home admission or death from any cause in 30 day survivors of OHCA who undergo bystander CPR or bystander defibrillation compared to those who do not receive bystander intervention.
  • Increasing rates of bystander interventions in Denmark during the course of the study period was associated with decreased rates of anoxic brain injury, nursing home admission, and all-cause mortality

What this means for EMS:

Denmark has instituted widespread initiatives including mandatory and voluntary CPR training, dissemination of automated external defibrillators throughout the country, health care professionals at emergency dispatch centers and dispatcher-assisted CPR. System wide measures and efforts to educate the lay public on BLS skills including high quality CPR and use of automated external defibrillation, is a critical step in both increasing survival rates from OHCA and improving functional outcomes for patients.