title: Epidemiology and outcomes of out-of-hospital cardiac arrest in a developing country-a multicenter cohort study.
abstract: Out-of-hospital cardiac arrest (OHCA) is one of the leading causes of death and disability worldwide. Overall survival after an OHCA has been reported to be poor and limited studies have been conducted in developing countries. We aimed to investigate the rates of survival from OHCA and explore components of the chain of survival in a developing country.
  
  
  
  We conducted a multicenter prospective cohort study in the emergency departments (ED) of five major public and private sector hospitals of Karachi, Pakistan from January 2013 to April 2013. Twenty-four hour data collection was performed by trained data collectors, using a structured questionnaire. All patients ≥18 years of age, presenting with OHCA of cardiac origin, were included. Patients with do-not-resuscitate status or referred from other hospitals were excluded. Our primary outcome was survival of OHCA patients at the end of ED stay.
  
  
  
  During the three month period, data was obtained from 310 OHCA patients. The overall survival to ED discharge was 1.6 % which decreased to 0 % at 2-months after discharge. More than half (58.3 %) of these OHCA patients were brought to the hospital in a non-EMS (emergency medical service) vehicle i.e. public or private transportation. Patients utilizing non-EMS transportation reached the hospital earlier with a median time of 23 min compared to patients utilizing any type of ambulances which had a delay of 7 min hospital reaching time (median time 30 min). However, patients utilizing ambulances with life-support facilities, as compared to all other types of pre-hospital transportation, had the shortest time to first life-support intervention (15 min). Most of the patients (92.9 %) had a witnessed cardiac arrest out of which only a small percentage (2.3 %) received bystander CPR (cardio pulmonary resuscitation). Median time from arrest to receiving first CPR was 20 min. Only 1 % of patients were found to have a shockable rhythm on first assessment.
  
  
  
  This study showed that the overall survival of OHCA is null in this population. Lack of bystander CPR and weaker emergency medical services (EMS) leading to a delay in receiving life-support interventions were some of the important observations. Poor survival emphasizes the need to standardize EMS systems, initiate public awareness programs and strengthen links in the chain of survival.
authors.affiliation: Department of Medicine, Aga Khan University, First floor, Faculty Offices Building, Stadium road, P.O. Box 3500, Karachi, 74800, Pakistan. minaz.mawani@aku.edu.
authors.forename: Minaz
authors.initials: M
authors.lastname: Mawani
authors.affiliation: Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan.
authors.forename: Muhammad Masood
authors.initials: MM
authors.lastname: Kadir
authors.affiliation: Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan.
authors.forename: Iqbal
authors.initials: I
authors.lastname: Azam
authors.affiliation: International Health Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Amber
authors.initials: A
authors.lastname: Mehmood
authors.affiliation: Emory University School of Medicine & Rollins School of Public Health, Atlanta, GA, USA.
authors.forename: Bryan
authors.initials: B
authors.lastname: McNally
authors.affiliation: Department of Surgery Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors.forename: Kent
authors.initials: K
authors.lastname: Stevens
authors.affiliation: Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan.
authors.forename: Rozina
authors.initials: R
authors.lastname: Nuruddin
authors.affiliation: Department of Medicine, Aga Khan University, First floor, Faculty Offices Building, Stadium road, P.O. Box 3500, Karachi, 74800, Pakistan.|Karachi Institute of Heart Diseases, Karachi, Pakistan.
authors.forename: Mohammad
authors.initials: M
authors.lastname: Ishaq
authors.affiliation: Department of Emergency Medicine, Aga Khan University & Aman Health, Aman Foundation, Karachi, Pakistan.
authors.forename: Junaid Abdul
authors.initials: JA
authors.lastname: Razzak
mesh_terms: D000328:Adult; D000368:Aged; D000552:Ambulances / Q000706:statistics & numerical data; D016887:Cardiopulmonary Resuscitation / Q000706:statistics & numerical data; D003906:Developing Countries / Q000706:statistics & numerical data*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008020:Life Support Care / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D058687:Out-of-Hospital Cardiac Arrest / Q000453:epidemiology* / Q000401:mortality; D010154:Pakistan / Q000453:epidemiology; D011446:Prospective Studies; D013997:Time Factors; D061665:Time-to-Treatment
keywords: Chain-of-survival; Out-of-hospital cardiac arrest; Survival