Dissertation Submitted In Partial Fulfillment Of The

A PILOT STUDY ON RETURN OF SPONTANEOUS CIRCULATION AMONG PATIENTS WITH

CARDIOPULMONARY RESUSCITATION PERFORMED IN EMERGENCY DEPARTMENT, HOSPITAL UNIVERSITI

SAINS MALAYSIA by

DR. CHEW KENG SHENG

Dissertation Submitted In Partial Fulfillment Of The

Requirements For The Degree Of

Master Of Medicine (EMERGENCY MEDICINE)

UNIVERSITI SAINS MALAYSIA

MAY 2007

ACKNOWLEDGEMENT

Special thanks to my supervisors. Associate Professor (Dr.) Kamuruddin Jaalnm and Dr. ldzwan Zakaria filr their valuable supports and guidance throughout the entire process or preparing and checking the manuscript.

Thanks to Dr. Nik I lishamuddin Nik Abdul Rahman as the head of the 1 :mergeney Department for his support and encouragement.

Thanks to Dr. Wan Aasim Wan Adnan and Dr. Rashidi Ahmad lllr their valuable advice f()r this dissertation.

My appreciation goes also to lecturers ami colleagues from Community Ilcalth Department for the statistical analysis input.

Thanks to my alma mater. Pusat Pengajian Sains Perubatan

(PPSP).

Universiti Suins Malaysia. I am always proud to be a student of USM. and I am extremely grateful to be tutored by many great lecturers and teachers ii'om my lirst to tinal years as medical student (

1995-19(9)

and as well as during my current master in medicine training.

It

is also a great honor for me to be given the privilege

10

be a trainee lecture here in

my

nwn alma mater.

Lastly. special thanks to my family. especially my

wile.

Urace Phua. I(}I' her constunt support and encouragement. especially during the nights of preparing and re-preparing this Jissertation ll1<.lI1l1scripl. Shl! has always bl!en a dl!ar darling to me.

II

TABLE OF CONTENTS

Acknowledgemcn

t

List oCTablcs List or Figures

List

of Abbreviations Abstrak

Abstract

Chapter 1 Introduction Chapter 2 Objectives

Chapter

3

Liter~lturc Review 3.1

... ...,

.)

....

3.3.

3.4 3.5

3.6

3.7 3.8

Background And Pathophysiologic Basis Out-Or-Hospital Cardiac Arrest

In Ilospital Cardiac Arrest Age Groups

Gender Di lTcrences Working Shills

Trauma Related Cuuses

Initial Cardiac Arrest Rhythms

Chapter'" Methodologv

4.1 Resl!un.:h QUl!slions

4.2

Study Design 4.3

Study

Duratiol)

.... A Stud) l.ocaLioll 4.5 Study Sampll!

11

VII

VIII

x

XI

XIV

<.)

10 10 12 14 15 16 17 17 17 19 19 19

Il)

20

III

4.6 [nclusion And Exclusion Criteria

4.7

Sampling Method And Sampling

Size 4.8

Dclinitions

Of

Terms

4.9

Variables

4.10 Flow

Chm1

Chapter 5 Results

5.1 General

5.1.1 Frequencies According

To Age

Groups 5.1.2 Frequencies According To Races

5.1.3

Gender

Achit:vemel1l

Of ROSe

Regardless

Of

Its Duration And

ROSe

Until Admission To Ward

5.3

Typt:s or Arrest And

ROSe

5.4

Typt:s

or

Arrest And

ROSe

Until Ward Admission 5.5. The Presence or Emergency Physicians And ROSC 5.6 Tht: Presence Of Emergency Physicians And

ROSe

Until

Admission To Ward

5.7

The Presence Of Emergency Medicine Resident And

ROSe 5.8

The Presence or Postgraduate Students And ROSe Until

Admission To Ward

21 22 22 25 27 28

28

28 28

..,.., -'- '"'..,

J ...

"'I..,

-'-

36 36 39

39

~I

5.9 Working Shins

41

5.10

Working

Shills And

ROSe

Aehit:vt:d Regardless OrWhelhcr 45

Sustailll':t.i

{lnlil /\dmissio/l 1'0

Ward

5.

J

I Worh.ing Shilis :\Jld Rose Achieved ,\nl! Suslaillcu

Ilntil

Admissio/l To Ward

1\

5.12 Bystander CPR 48

5.13 Bystander CPR And ROSe 48

5.14 Witnessed Arrest ₅₁

5.15 Etiologies

or

Cardiac Arrest And

ROSe

51

5.16 Etiologies

or

Cardiac Arrest And

ROSe

Until Admission To Ward 53

5.17 Gender And ROSe

53

5.18 Gender And ROSe Until Admission To Ward 53

5. t l) Initial Rhythms And ROSe 57

5.20 Initial

Rhythms

And ROSC Until Admission To Ward 57 5.21 Delay OrePR From Onsel Of Cardiac Arrest 60

5.22 Zones Where Resuscitation Occur 60

Orotruchcal Intubation 60

5.24 Summary

or

Findings 62

Chapter 6 Discussion

6.1 Overview 66

6.2 The Number

or

OltA And iliA Cases 69

6.3 The Presence

or

Emergency Physician ⁷²

6.4 The Presence

or

Emergency Medicine Residents 73

6.5 Working Shills 74

6.6 Trauma (. 'ases 75

6.7 fnitiul Cardiac Arrest Rhythms And Rose 76

6.8 0111\ Subgroup Analysis

or

Bystander Cpr And Wilnessed Arrests ⁷⁷ 6.() I.imitations OfSludy

6.1 () Fullln: Works ^XO

Chapter 7 ('ondusion

X2

\

Bibliography Appendix A

83 87

\ I

Table 5.1:

Table 5.2:

.LIST OF TABLES

Percentage of ROSe Regardless

Of

Whether It Was Sustained To Admission To Ward

Pl!rcentagc of ROSe Sustained To Admission To Ward (Survival To Admission)

64

65

\1\

Figure 1:

Figure

5. I:

Figure 5.2:

Figure 5.3:

Figure 5.4:

Figure 5.5:

Figure 5.6:

Figure 5.7:

Figure 5.8:

Figure 5.9:

Figure 5.10:

Figure 5. I I:

Figure 5.12:

Figure 5.13:

Fig.ure :'.I~:

Figure 5.15:

LIST OF FIGURES

The Concept

of

the Chain of Survival

4

Pic Chart showing the percentage and number

or

^{cardiac 29}

arrest cases according to either in-hospital (IliA) or out-or- hospital (OIlA) arrests

Percentage

or

Cardiac Arrest Cases According To Age 30 Groups

Pic Chart Showing Percentage And Number

or

Cardiac 3 I Arrest Cases According To Races

Achievement of ROSC regardless of whether it was 33 sustained until admission to ward

Achievement of ROSe sustained until admission to ward 34 Percentage of IliA and OIIA Cardiac AITcst Patients to 35 achieve ROSe regardless of whether it was sustained until admission to ward

Percentage of IHA and 01 IJ\ Cardiac Arrest Patients to 37 achicve ROSe sustained until admission to ward

Emergency Physicians and ROSe achieved regardless 38 whether it was sustained until admission to ward

Rose

achh.:vcd until admission to ward according to 40 avuilability of emergency physicians

Emergency Medicine Residents and ROSe achievcd 42 regardkss whether it was slistained until admission to ward Emerl.!encv Medicine Residents anll

-

^., ROS(' achieved und

-

43 sustained until admission to ward

Number orCarliiae Arrest cases according to Working 44 Shifts

Working shins and ROSe :.lchic"cd rcgardkss whether it 46

\vas slIstained to admission lo ward

\J\'orking Shifts and

Rose

achicvcd and sllslail1~d unlil -+ 7 admissioll 10 \\-ard

NlIlllb~r of hystamil:r CPR Jonc a 111 0 lit! nalienl!"> Iv\ ith 01 It\ ~()

\ III

Figure 5.16:

Figure 5.17:

Figure 5.18:

Figure 5.19:

Figurc 5.20:

rigure 5.21:

Figurc 5.22:

Figure 5.23:

Figure 5.2 .. k

Bystander CPR and achievement of ROSe regardless of 50 whether it was sustained to admission to ward among 01 [A patients

Etiologies of cardiac arrest and percentage of ROSe 52 achieved regardless of whether it was sustained until

admission to ward

Etiologies of cardiac arrest and percentage of ROSe 54 achieved and sustained unti I admission to ward

Gender and percentage of ROSe achieved regardless or 55 whether it was sustained until admission to ward

Gender and percentage of ROSe achieved regardless of 56 whether it was sustained until admission to ward

Initial Cardiac Arrest Rhythms and Percentage of ROSe 58 achieved regardless ofwhclher it was sustained tu

admission to ward

(nilial Cardiac Arrest Rhythms tmd Percentage or

Rose

⁵⁹

sustained to admission to ward

Zones Where Resuscitation Occur 6 t

Orotracheal Intubation During Resllscitation 63

IX

ACts

AED AlIA

BLS

CPR

DNAR

ECC

ECG

ED EMS

ERe

HUSM

ILCOR lilA

NRCPR

OIlA OPALS

Rose

PEA PI lASE

VF

VT

LIST OF ABBREVIATIONS

Advanced Cardiac Lite Support Automated External Defibrillator American I kart Association Basic Life Support

Cardiopulmonary Resuscitation Do Not Attempt Resuscitation Emergl.!l1cy Cardiovascular Care Electrocardiography

Emergency Department Emergency Medical Services European Resuscitation Council lIospitulUniversiti Sains Malaysia

International Liaison Committee on Resuscitation In IIospilal Cardiac Arrest

National Registry of Cardiopulmonary Resuscitation

OUi of I

fospital Cardiac Arrest

Ontario Prchospital Advanced Life

Support

Return

ofSponlaneous

Circulation

Pulsclcss Electrical Activity

Prc-Ilospital

Arrest

Survival I:valualion

Study

Ventricular J:ibrillation

V

cnlricular Tachvcardiu

ABSTRAK

KA.HAN PERINTIS I)ENCAPAIAN I)ENGEMBALIAN SIRKULASI

SPONT

AN

ATAU "RETURN OF SPONTANEOUS CIRCULATION" (ROSC)

IlALAM

KALANGAN PESAKIT YANG DIIlERI RAWATAN RESUSITASI

KAROIOPULMONAIU 01

.JABATAN KECEMASAN, 1I0S1)ITAL UNIVERSITI SAINS MALAYSIA

Pcngcnalan

Rcsuscitasi kardiopulmonari

(CPR)

mcrupakan scbahagian kCl:ia asas rutin yang as as bagi scseorang doktor di Jabatan Pcrubatan Kcccmasan. Scmcnjak lahlll1

J

950an. tcknik

CPR

scntiasa bcrkcmbang majll. Pcngcnalan "Utslcin style"

scbagai cam untuk melaporkan hasil llsaha

CPR

telah mempertingkatkan kcbcrkcsanan pcnyclidikan yang piawai dulum bidang

penting ini.

Pcmiawaian dcfinisi

dan

pcncontoh cara pclaporan juga mcnggi.lIakkan pcrbandingan hasil-hasil pcnyelidikan.

Nan1lm. tidak banyak usaha pcncrbitan di Malaysia dalam bidang inL K,uian pcrinlis ini bcrtujuan unluk mcnilai kcbcrkcsanan hnsil usahu

CPR

yang dilakukan di Jabatan Kccemasan

(ED).

Hospital Univcrsiti Sains Malaysia

(f IUSM). Dua o~icktjf

dalam

k~iian

ini adalah

I.

suma ada

ROSe

dicapui atau tidak (lanpa mcngira sam a ada

ROSe

itll dupat dikckalkan sumpai pcsakil dimasukkan kc wad)

2. sarna

ada

ROSe

yang kckal sampai pcsakit dirnasukkull kc wad dicapai atau tiuak

Metodulogi

Kujian ini dilakukan scoagai

sall!

kajian pcrmcrhatiall prospcktiC

SCIl1UH

pcsakil yang

dibcri

rawalan CPR di Fl). IILSM dimaslIkkan dalum kajian ini. Kajian ini dijalankan dalam h!mpoh sctahull. iailll dad Mac 2()()S hingga !\t1m,; 2006. Kcs-kl!s

jantung lcrhl!nli

yallg

mana

CPR

tidak

dilal\ukan klah dikccllalika" d:!ripad:l !·~~l.ibl: :i1i.

Xl

Kcputusan

Seramai 63 pcsakit jantung tcrhenti dianalisu. Oaripada jumlah 63 pcsakit. 23 (36.5%) dikatcgorikan scbagai "jantung tcrhenti di luar hospital" atuu

"Ollt~

of~hospital

arrests (OHA),'. Sdebihnya 40 (63.5%) yang lain dikutegorikan sebagai

"jantung terhenti di oalum hospital" atau

"in~hospital

arrests

(II fA)".

Daripaoa jllmlah 63 pcsakit. 19 (30.2%) rncneapai

ROSe

tanpa mcngira sarna aduROSC itll dapal dikekalkun sampai pcsukit dimasukkan kc wad. Yang sclcbih 44 pesakit (69.9%) tidal< mencapai

ROSe

langsung. Ilanya 6 pcsakit (9.5%) mencapai

Rose yang kckal sampai pcsakil dimasukkan kl.! wad, manakala yang sclebih 57 pcsakit (90.5%) tidak.

Dalam

sub~kajian

Ol-IA.

ROSe

yang dicapai tanpa mengira sarna ada ROSe

itll

dikckalkan sarnpai kcmasukan wad adalah hanya 17.4% (n'""'4) and

ROSe

kekal sehingga kemasukan wad adalah hanya 4.31% (n=I). Dalam

sllb~kajian

II-IA.pula,

ROSe

yang dicapai tanpa mengira sarna ada Rose dikclmlkan sampui kcmasukan wad adalah scdikit Icbih baik, iaitu pada 37.5% (n= 15). rnanakala

ROSe

yang dicapai schingga kcmasukan wad adalah sedikit Icbih baik pada 12,51% (n--5). PeIuang scscorung pcsukit dcngan lilA untuk mencapai ROSe tunpa mengira sumu uda Rose

itll kckal schinggu kcmasukan adalah Icbih kUl'ung dun kali ganda (37.5%) berbanding dengan scscorung pesukit den gun

01 fA (

17.41%).

Fuklor lain yung dikuitkan dcngan peluang hidllP yang lebih tinggi udalah pcmulaan

CPR

yung uwal dulum h:mpoh 5 minil. kehudiran pukar perubutl.lll kccemasun scmasa (,PR. kL:hadirall rcsidcn pcrubaLUII kcccmasull scmusa CPR dan rilmu pctnulaan

)·ung

holch dihcri n:njalan dcktrik.

.\11

Kesimpulan

Secara keseluruhan, ROSC yang dicapai tanpa mengira sarna ada ia kckul schingga kcmasukan wad adalah 30.2% dan ROSe yang dicapai sehingga kcmasukan wad (hidup sumpai kemasukan wad) adalah hanya

9.5%.

Faktor yang kcmungkinan mcnpengaruhi hasil CPR dcngan positif (yakni meninggikan pcluang pcncapaian

ROSe

tanpa mcngira sarna ada

ROSe

kckal schingga kcrnasukan wad dan

ROSe

sehingga kcmasukan wad) adalah lilA scbl.lgai jcnis juntung tcrhcntL lIsaha CPR yang awnl dalum tcmpoh 5 minit sclcpas jantung tcrhcnti. kchadirun pakar pcrubalan kcccmusan. kchadiran rcsidcn pcrubatan kcccmusan dtm ritmajantung yang bolch dibcri rcnjatan clcktrik.

Kcsimpulun

Sccaru kcscluruhan. pduang hidup pcsakit dcngan jantung tcrhcnti adalah rcnuah. Pcnyclidikan yang Icbih lanjut untllk

mcngk~ji

ttlktor-faktor yang mcnpengaruhi hasil CPR adalah dipcrlllkan.

XIII

ABSTRACT

A PILOT STUDY ON RETURN OF SPONTANEOUS CIRCULATION (ROSe) AMONG PATIENTS WITH CARDIOPULMONARY RESUSCITATION (CPI{) PERFORME» IN EMl~RGENCY DEPARTMENT, HOSPITAL UNIVERSITI SAINS MALA YSIA

Introduction

Cardiopulmonary resuscitation (CPR) is an integral part of routine job prescription for emergcncy medicine doctors. Since the 1950s, the technique of

CPR

is ever improving. The introduction of the Utstein's style of reporting of outcomes or

CPR has H.1l1her enhanced standardized research works in this vital area. The standardization of dctinitions and reporting template has also allowed more meaningful comparison of one study with another. Dcspitc that. there has not been many published works in this area in Malaysia. This pilot study serves to look into the effectiveness of CPR perli.)rmed in Emergcm;y Department

(ED),

Hospital Univcrsiti Sains Malaysiu (IIUSM). Two end points of this study arc

I. whether return of spontaneous circulation

(ROSe)

achieved regardless of whether the Rose was sustained until admission to ward

2. whcther

ROSe

aehievcd and sustained until admission to ward. This is also known as survival to admission

Methodology

This study was conducted us a prospective. observational study. All patients with CPR done in ED. IIUSM were included in this study. The stuJy was undertaken for a period or one yl.:i.lr. from March 2005 to March 2006.

<.

'ardiac arrl.:sl

cases \\there CPR was nol pcrlilrllll.:J \-vere excluded lhllll the study.

XIV

Results

A

total of

63

cardiac arrest patients were analyzed. Out of these

63

patients, 23

(36.5%) of

the

63

patients were categorized as out-or-hospital Arrests (aHA) whereas the other 40

(63.5

^I

Vo)

patients had an in-hospital Arrest (II-IA).

In total. out of these 63 patients, 19 (30.2%) of them had ROSe regardless of whether the Rose was sustained until admission to ward. The other

44

(69.8%) did not achieve ROSe at all. Only 6 patients (9.5%) achieved ROSe until admission to ward (survival to admission) whereas the other 57 patients (90.5%) did not.

In

the aHA subgroup analysis. ROSe achieved regardless

of

whether it was sustained until admission to ward is only

17.4%

(11=4) and Rose achieved until

admission to ward

is

only

4.3%

(n=l). In the lilA

subgroup

analysis,

ROSe

achieved

regardless

of

whether it was sustained until admission to ward is

slightly

better at

37.5%

(n~'I5) and ROSe achieved until admission to ward is

slightly

better at 12.5%) (n~5).

The chance of a patient with IliA to achieve Rose regardless of whether the ROSe was sustained until admission to ward

wu:;

about two times (37S%) higher compared to

a patient with OHA

(17.4%) (p:-·O.094).

Other factors

found

to

be associated

with

higher

chance

or

survival rate arc early commencement

of

CPR within 5

minutes. presence or emergency physicians

during CPR. the presence

or

emergency medicine residents during CPR and shockable rhythm as the initial cardiac arrest rhythm.

Conclusion

Overall. ROS(' achieved regardless

or

whelher it was slistained lIIHil admission to ward is only 30.2(!li. and

Rose

achieved unlil admission to ward (survival to admission) is only 9.5%).

Factors that possibly innuence the outcomes positively (which means increasing the chance of achieving ROSe and

Rose

until admission to ward) are in- hospital Cardiac Arrests as the type of arrest. early commencement of CPR within 5 minutes, presence of emergency physicians, presence of emergency medicine residents and shockable rhythm as the initial cardiac arrest rhythm. Out of these tive tactors, only shockable rhythm as the initial cardiac arrest rhythm is statistically significant.

.x VI

1. INTRODUCTION

Modcrn cardiopulmonary resuscitation (CPR) is, without a shadow of doubt, closely linked with the name of Peter Satar (1924-2003). The enormity of his contributions since the 1950s. including

his

landmark paper

of

mouth-lo-mouth ventilation (Baskett, 200 I), earned him titles sllch as "Father of Modern Resuscitation"

(Baskett, 2003) and "Father of CPR" (Oral1sky, 2003). Among his other insurmountable list or works include the development of thc technique of head-tilt.

chin-lift and jaw thrust to open obstructed airway in unconscious victims (Baskett.

200 I). the importance of the concept

of

bystander-initiated resuscitation (Moscsso and Paris, 2003) and the design of the well-known and widely util ized resuscitation dummy called '"Resusci-Anne" together with Asmund Laerdal, a toymaker Ii-om Norway.

(Baskett. 200 I. Baskett, 2003, Oransky. 2003).

About the same time (around 1 960s). Kouwenhowcn, togcther with his colleagues Knickerbocker llnd Jude. were experimenting with detibrillation and rediscovercd the dlicacy of external chest compression to produce a passable circulation. first in canine models. then in humans (Baskett. 200 I. Baskctt. 20(3). With his ingenuity. Safar combined the techniques of airway positioning. ventilation. and external chcst compression

to

produce the current technique

of

basic lit~ support (Baskett. 200 I) that has stood the test of time.

I~\tcr since then. the technique of resuscitation is ever improving. with the American lleart Association (AliA). beginning in 1966. held various conlcrences 0/1

CPR (;\11/\.2000). Experts from uthel' m .. ~ior world rcsuscitation coul1l:ils wcre illvih.:d durillg these COl1ll:n:rll.:es to cl1l;ouruge illlernatiollal intellectual exchange. Besides I\IIA making various rccommelldutions on CPR and clllcrgcncy cardiovascular can.:

(ECC), the European Resuscitation Council (ERe) has also produced various guidelines in this area.

Nevertheless, due to lack of uniformity in terms of definitions and research criteria and the disparity in terms of methodologies and results from one study to another. efforts to make useful comparisons between these studies were hampered.

To address this m~or concern, representatives of the AHA. the European Resuscitation Council, the Heart and Stroke Foundation of Canada, and the Australian Resuscitation Council held two conferences in 1990 and 1991 at the ancient abbey of Utstein on an island ncar Stavanger, Norway.

As a result of these conferences, the standardized Utstcin style template tor reporting out-ot:'hospitals cardiac was produced. In 1997, a similar Utstcin style tor reporting in-hospital cardiac arrests was produced (Cummins el al.. 1997).

Since thcn. the Utstein-style definitions and reporting templates have been used extensively in published outcome studies of cardiac arrest. The usc of these standardized definitions and templates have certainly proven to be beneficial: as

it

hus contributed to a greater understanding or the clements of resliscitation practice and has tacilitated progress toward an international consensus on science and resuscitation guidelines (Jacobs et al .. 20(4). The first consensus was the International Guidelines 2000 Conference on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (I :CC).

In other words. with sllch an intcrnutional concerted cf/(Jrl. backed with scientiJic evidences, a harmonious recommendation and guideline in the practice or CPR and FCC was able to be developcd to heneJit. not only in-hospital cardiac arrest 'patients. but also the clIllll11uniLy as a whole. especially in relation to out-of-hospital

arrests.

Nevet1heless. although the Utstein~style reporting template has many benetits. it also has several limitations. These templates. for instance. were found to be too complex and both their recommended core and supplementary data have clements that are logistically difticult to collect. For example, it is ditlicult for rescuers to estimate and record specific intervals accurately during the resuscitation event (Fredriksson et al .. 20(3).

In addition, because there are two different templates for in-hospital and out-ot-:'hospital cardiac arrests, this has resulted in inconsistencies in terminology between these two templates. As a result, efforts to adequately integrate and compare individual research studies were hindered (Fredriksson el at.. 2003).

To address these issues, in April 2002, an ILCOR task force meeting was held in Melbourne, Australia to review and revise the Utstein definitions and reporting templates. The objective of this task force was to develop a single. simple. and practical template for uniform collection and reporting of data on cardiac arrest. Out of this meeting, a practical revised Utstein template was developed to enable unil()rm collection and tracking of datu to facilitate better continuous quality improvement within hospitals. emergency medical services (EMS) systems. and communities. It also enahles comparisons across systems

tor

clinical benchmarking to identity opportunities tor improvement (Frcdriksson el at..

2003).

Cardiac arrest is the cessation of cardiac mechanical activity us confinned hy the absence of signs of circulation. Cardiopulmonary resuscitation is an attempt to restore spontaneolls circulation by performing chest compressions with or without ventilations (Jm:ohs elal.. 20(4).

Tedlllically. cardiac arrests CUll be divided into ()ul~or·h()spilal cardiac arrests (OIIA) or in-hospital cardiac arrests (II [A). This distinction is important

,

.l

because any cardiac arrest that occurs in an out-of-hospital setting would most probably depend entirely on the initiati ves of bystanders to start CPR. Nevertheless, the survival rate ofOHA generally still remains low (Jacobs et al., 2(04).

The chance of survival of cardiac arrest is depended on the prompt initiation of sequentially linked actions known as

the

chain of survival. The links in this chain arc carly recognition of signs of cardiac arrest, carly activation of emergency medical services, carly initiation of basic cardiopulmonary resliscitation, carly ddibriIlation and early initiation of advanced cardiac liti: support. Every chain is important and weakness in any link would lessens the chance of survival of out-of- hospital cardiac arrests (Cummins et aI., 1(91). The concept orthe chain of survival is illustrated in Figure 1 below.

Early Access

Figure I: The Concept of the Chain of Survival

Early ACLS

Out of the JlJUr chains. the first three involved the participation of the public including Jumily members and rriends to improve the chance

or

out-or·hospital cardiac arrests (Cummins el al.: 1(91). This explains the importance

or

bystander CPR as a mcans of "buying time" by temporarily preserving the vital organs like the heart and bruin (Cummins el al.. 1')91). For example. the publk could he trained not only for earlv reeo!.!nition of cnrdial: arrest, hUl also rel:o!-!.nition of common symptoms that may

.;

- -

heralJ a l:ardiac arrest sllch as chest pain. 1"hI.:y ShDUIJ alst) bc li.luglll to makc carly del:ision to activate the emergency mcdical services as well as be lraincJ to proviJe aCl,;unHe alld essellliai delalls 01 lhe emergency via telephone (<.'ulllmllls l!1 al .. 1l)9 I).

The public can also be trained to perform bystander CPR. Bystander CPR is defined as CPR performed by a person who is not responding as part of an organized emergency response system to a cardiac arrest (Jacobs el al., 2004).

For example. Ilcrlitz eJ al. found that CPR initiated by a bystandcr helps maintain ventricular tibrillation and triples the chance of surviving a cardiac arrest outside hospital. Furthermore. it seems to protect against death in association with brain damage as well as with myocardial damage (Berlitz el al .• (994).

Bystander CPR

In general, the overall survival rates of out-or-hospital cardiac arrests are less than 5% in most communities and there is no evidence that these rates are increasing, despite extensive usc of advanccd treatments and technology (Vaillancourt and SticH. 20(4).

The Ontario Prehospital Advanced Life Support (OPALS) Study was

a

multicenter. controlled clinical trial conducted in 17 locations to assess the incremental etlect on the rate of survival after out-of-hospital cardiac arrest

by

adding the advanced cardiac life support progmm to the I!xisting program of rapid detibrillation (Vaillancourt and Stiell. 2004).

This study shows that though adding advanct.:d Ii tc support to rupid- defibrillation phasl! has increased the rate of admission to a hospital signilical1tly ([><0.00 I). the rate

or

survival to hospital discharge did not (P-;;·O.83). In other words.

the addition of advanced-Iil'c-support interventions did not improve the rate of survival after out-oC-hospital cardiac arrest in a previously optimized emergl!l1cY-l1ll!dical- services system of rapiu defibrillation. But rather. this SllIUY shows to liS lhat health care planners should make hyslanuer cardiopulmol1C.lr) resuscitation and rapid-

:)

defibrillation responses a priority tor the resources of emergency-medical-services systems (Vaillancourt and SticH. 2004),

[ronically. even though about three-quarters of out-of-hospital cardiac arrests occlIr at home or private residences rather than in public places (Iwami el ai., 2(06), bystander-initiated CPR most frequently takes place in public places such as the street (I1erlitz el al., 1(94) and this is usually performed by health care workers (Bossacrt and Van Hoeyweghen, 1989). Not surprisingly. arrest patients in public or in the work place had a higher chance of being found in ventricular fibrillation and survival than those at a private residence (Herlitz e/ al .. ) 9(4),

Back to our own local scenario, despite such an intensive intemationul effort to improve the standard of CPR and ECe. not only there is not a parallel increased of local published research works in this critical area of CPR, but rather. the number of such publications in Malaysia is dismally low. Chan in 1997. who studied the outcomes of CPR peri()lmcd in six Mulaysian district hospitals, found that as high as up to almost 60% of cases were inadequately resuscitated. Many reasons were cited.

including starf nurses who tailed Lo initiate chest compression and to provide positive pressure ventilation through bag-valve-mask. inadequate duration of resuscitation and incomplete resuscitation trolleys (Chan. 19(7).

With that in mind. this pilot study to look into the outcomes of cardiopulmonary resuscitation done in emergency department is undertaken. It is ulso seen as an attempt to gauge the degree

or

improvement (since the study

by

Chan seven years ago) in the outcomes orC!>R performcd in one ofthc univcrsity teaching hospitals with a postoraduah: prooram in I·:mcrll.ellcv Mcdicinc. _{~ 0 ~-}

This study is designed as a pilDl study dw.: to lack of previolls local data.

Moreover, data from previous worldwide studics unl()rlllllutely vary greatly !i'om OIlC

study with another. For example. the outcome of survival to hospital discharge was cited to vary from 15% to 40% n·om one study to another. Reasons for such disparity include different sample population selection criteria (Berlitz el £1/ .• 2000).

Furthermore. almost all published studies from other countries have their endpoints more than just the question of achieving ROSe. Rather.

it

includes endpoints like survival until hospital discharge and survival at six months.

The other problem with studies done previously is that most of these studies include ePR done in other wards rather than just conJined to Emergency Department, which is the design of this study us one of its main objectives is to identity factors in the Emergency Department that would possibly determine the success in achieving ROSe.

The closest to our local setting was a study done in Tan Tock Seng Hospital. Singapore (Lim and Thrun. 200 I) where ROSe achieved in 17.4% of patients.

Even that. the design of that study was exclusively limited to only out-of-hospital arrests. rather than include both in-hospital and out-ot:hospital arrests. as st!cn in Emergency Department.

Another study was done in a 2300-bed university hospital in Thailand to.

similarly. look into the outcomes and quality of IlIA CPR done on 639 victims t(Jr a period of one year as well as tactors affecting the outcomes of CPR.

It

was found thut 394 (61.7(%) achieved restoration

or

spontaneous circulation and 44 path.:nl~ (6.9%))

survived to discharge (Sur..tscranivongse el ,,/.. 20(6).

This pilot study looked into two

or

the most basi<.: end-points mliler than more sophisticated end-points. The end-poinls are firs!ly. achievement 1)1' Return ()f Spolltaneolls Circulation (ROSe) n.:gardlcss of whether the ROSe was sl1slUil1~d 1I1lli I

7

admission to respective wards and secondly, achievement of Rose that was sustained until admission to respective wards or also known as survival to admission.

While it cannot be denied that certainly not all ROSe achieved would translate into success rate of survival until discharge from the hospital, nevertheless, achieving ROSe represents the very tirst step in at least giving hope ti)r survival to the cardiac arrest victims. No ROSe achieved after a certain period of ePR means no hope at all for the cardiac arrest victims.

Furthermore, in the Utstein's style definition, a survived event for OHA cases IS now defined as achieving sllstained ROSe with spontaneous circulation sullicient enollgh until admission and transter of care to medical staff at the receiving hospital rather than more elaborative definitions. And for the in-hospital setting, a survived event is ddined as achieving sustained ROSe for >20 min (Jacobs et

£II..

2004). With that in mind, taking the achievement of ROSe per sc as end-points in this study can be seen as complying to what is prescribed as survived events of rcslIscitation by the Utstdn's style ddinitions. The detailed description of other terms derived n'om the Utstein's style definitions would be elaborated further in the literature review section. It is, there lore, with this hope of producing a local data as a foundation that this

pilot study is embarked upon.