title: Cardiocerebral resuscitation is associated with improved survival and neurologic outcome from out-of-hospital cardiac arrest in elders.
abstract: BACKGROUND
  Recent studies have shown that a new emergency medical services (EMS) protocol for treating patients who suffer out-of-hospital cardiac arrest (OHCA), cardiocerebral resuscitation (CCR), significantly improves survival compared to standard advanced life support (ALS). However, due to their different physiology, it is unclear if all elders, or any subsets of elders who are OHCA victims, would benefit from the CCR protocol.
  
  
  OBJECTIVE
  The objectives of this analysis were to compare survival by age group for patients receiving CCR and ALS, to evaluate their neurologic outcome, and to determine what other factors affect survival in the subset of patients who do receive CCR.
  
  
  METHODS
  An analysis was performed of 3,515 OHCAs occurring between January 2005 and September 2008 in the Save Hearts in Arizona Registry. A total of 1,024 of these patients received CCR. Pediatric patients and arrests due to drowning, respiratory, or traumatic causes were excluded. The registry included data from 62 EMS agencies, some of which instituted CCR. Outcome measures included survival to hospital discharge and cerebral performance category (CPC) scores. Logistic regression evaluated outcomes in patients who received CCR versus standard ALS across age groups, adjusted for known potential confounders, including bystander cardiopulmonary resuscitation (CPR), witnessed arrest, EMS dispatch-to-arrival time, ventricular fibrillation (Vfib), and agonal respirations on EMS arrival. Predictors of survival evaluated included age, sex, location, bystander CPR, witnessed arrest, Vfib/ventricular tachycardia (Vtach), response time, and agonal breathing, based on bivariate results. Backward stepwise selection was used to confirm predictors of survival. These predictors were then analyzed with logistic regression by age category per 10 years of age.
  
  
  RESULTS
  Individuals who received CCR had better outcomes across age groups. The increase in survival for the subgroup with a witnessed Vfib was most prominent on those<40 years of age (3.7% for standard ALS patients vs. 19% for CCR patients, odds ratio [OR]=5.94, 95% confidence interval [CI]=1.82 to 19.26). This mortality benefit declined with age until the >or=80 years age group, which regained the benefit (1.8% vs. 4.6%, OR=2.56, 95% CI=1.10 to 5.97). Neurologic outcomes were also better in the patients who received CCR (OR=6.64, 95% CI=1.31 to 32.8). Within the subgroup that received CCR, the factors most predictive of improved survival included witnessed arrest, initial rhythm of Vfib/Vtach, agonal respirations upon arrival, EMS response time, and age. Neurologic outcome was not adversely affected by age.
  
  
  CONCLUSIONS
  Cardiocerebral resuscitation is associated with better survival from OHCA in most age groups. The majority of patients in all age groups who survived to hospital discharge and who could be reached for follow-up had good neurologic outcome. Among patients receiving CCR for OHCA, witnessed arrest, Vfib/Vtach, agonal respirations, and early response time are significant predictors of survival, and these do not change significantly based on age.
authors.affiliation: Department of Emergency Medicine, Arizona Center on Aging, University of Arizona, Tucson, AZ, USA. jmosier@aemrc.arizona.edu
authors.forename: Jarrod
authors.initials: J
authors.lastname: Mosier
authors.forename: Ajit
authors.initials: A
authors.lastname: Itty
authors.forename: Arthur
authors.initials: A
authors.lastname: Sanders
authors.forename: Jane
authors.initials: J
authors.lastname: Mohler
authors.forename: Christopher
authors.initials: C
authors.lastname: Wendel
authors.forename: Jacob
authors.initials: J
authors.lastname: Poulsen
authors.forename: Jeff
authors.initials: J
authors.lastname: Shellenberger
authors.forename: Lani
authors.initials: L
authors.lastname: Clark
authors.forename: Bentley
authors.initials: B
authors.lastname: Bobrow
mesh_terms: D000328:Adult; D022561:Advanced Cardiac Life Support / Q000379:methods; D000368:Aged / Q000706:statistics & numerical data; D000369:Aged, 80 and over / Q000706:statistics & numerical data; D001130:Arizona / Q000453:epidemiology; D016887:Cardiopulmonary Resuscitation / Q000379:methods*; D004636:Emergency Service, Hospital; D004638:Emergency Treatment / Q000379:methods*; D005260:Female; D006323:Heart Arrest / Q000401:mortality / Q000628:therapy; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D012042:Registries; D012189:Retrospective Studies; D015996:Survival Rate; D013997:Time Factors; D017749:Total Quality Management; D016896:Treatment Outcome