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Bystander-initiated cardiopulmonary resuscitation can increase survival among patients with out-of hospital cardiac arrest. In this study, a mobile-phone positioning system to dispatch trained volunteers significantly increased rates of bystander-initiated CPR. Bystander-initiated cardiopulmonary resuscitation (CPR) before the arrival of emergency-medical-services (EMS) personnel is associated with a rate of survival among patients with out-of-hospital cardiac arrest that is up to three times as high as the rate among patients who do not receive such assistance. 1 , 2 Low rates of bystander-initiated CPR are a major obstacle to improved survival rates. 3 The usual approach to increase rates of bystander-initiated CPR has been to train as much of the public as possible. 4 However, this approach is associated with substantial costs and uncertain effects on rates of bystander-initiated CPR. 5 With the use of a mobile-phone positioning . . .

This study examined whether training in cardiopulmonary resuscitation increases the frequency of bystander CPR and the rate of survival. CPR performed before the arrival of emergency medical services was associated with a substantially greater 30-day survival rate. Out-of-hospital cardiac arrest is a major public health concern, given that there are approximately 420,000 cases in the United States and 275,000 cases in Europe annually. 1 – 3 Decreasing the time to treatment is crucial for improving outcomes in cases of cardiac arrest. 4 , 5 As stated in American and European guidelines, the most important response measures that currently can be taken outside a hospital setting are recognizing early that a cardiac arrest is occurring, placing an alarm call, performing cardiopulmonary resuscitation (CPR), and performing defibrillation. 6 , 7 Globally, CPR is taught to millions of people each year. In Sweden, more than 3 . . .

Background A substantial proportion of critically ill COVID-19 patients develop thromboembolic complications, but it is unclear whether higher doses of thromboprophylaxis are associated with lower mortality rates. The purpose of the study was to evaluate the association between initial dosing strategy of thromboprophylaxis in critically ill COVID-19 patients and the risk of death, thromboembolism, and bleeding. Method In this retrospective study, all critically ill COVID-19 patients admitted to two intensive care units in March and April 2020 were eligible. Patients were categorized into three groups according to initial daily dose of thromboprophylaxis: low (2500–4500 IU tinzaparin or 2500–5000 IU dalteparin), medium (> 4500 IU but < 175 IU/kilogram, kg, of body weight tinzaparin or > 5000 IU but < 200 IU/kg of body weight dalteparin), and high dose (≥ 175 IU/kg of body weight tinzaparin or ≥ 200 IU/kg of body weight dalteparin). Thromboprophylaxis dosage was based on local standardized recommendations, not on degree of critical illness or risk of thrombosis. Cox proportional hazards regression was used to estimate hazard ratios with corresponding 95% confidence intervals of death within 28 days from ICU admission. Multivariable models were adjusted for sex, age, body mass index, Simplified Acute Physiology Score III, invasive respiratory support, and initial dosing strategy of thromboprophylaxis. Results A total of 152 patients were included: 67 received low-, 48 medium-, and 37 high-dose thromboprophylaxis. Baseline characteristics did not differ between groups. For patients who received high-dose prophylaxis, mortality was lower (13.5%) compared to those who received medium dose (25.0%) or low dose (38.8%), p  = 0.02. The hazard ratio of death was 0.33 (95% confidence intervals 0.13–0.87) among those who received high dose, and 0.88 (95% confidence intervals 0.43–1.83) among those who received medium dose, as compared to those who received low-dose thromboprophylaxis. There were fewer thromboembolic events in the high (2.7%) vs medium (18.8%) and low-dose thromboprophylaxis (17.9%) groups, p  = 0.04. Conclusions Among critically ill COVID-19 patients with respiratory failure, high-dose thromboprophylaxis was associated with a lower risk of death and a lower cumulative incidence of thromboembolic events compared with lower doses. Trial registration Clinicaltrials.gov NCT04412304 June 2, 2020, retrospectively registered.

Background Hyperoxemia may aggravate reperfusion brain injury after cardiac arrest. The aim of this study was to study the associations between different levels of hyperoxemia in the reperfusion period after cardiac arrest and 30-day survival. Methods Nationwide observational study using data from four compulsory Swedish registries. Adult in- and out-of-hospital cardiac arrest patients admitted to an ICU, requiring mechanical ventilation, between January 2010 and March 2021, were included. The partial oxygen pressure (PaO 2 ) was collected in a standardized way at ICU admission (± one hour) according to the simplified acute physiology score 3 reflecting the time interval with oxygen treatment from return of spontaneous circulation to ICU admission. Subsequently, patients were divided into groups based on the registered PaO 2 at ICU admission. Hyperoxemia was categorized into mild (13.4–20 kPa), moderate (20.1–30 kPa) severe (30.1–40 kPa) and extreme (> 40 kPa), and normoxemia as PaO 2  8–13.3 kPa. Hypoxemia was defined as PaO 2  < 8 kPa. Primary outcome was 30-day survival and relative risks (RR) were estimated by multivariable modified Poisson regression. Results In total, 9735 patients were included of which 4344 (44.6%) were hyperoxemic at ICU admission. Among these, 2217 were classified as mild, 1091 as moderate, 507 as severe, and 529 as extreme hyperoxemia. Normoxemia was present in 4366 (44.8%) patients and 1025 (10.5%) had hypoxemia. Compared to the normoxemia group, the adjusted RR for 30-day survival in the whole hyperoxemia group was 0.87 (95% CI 0.82–0.91). The corresponding results for the different hyperoxemia subgroups were; mild 0.91 (95% CI 0.85–0.97), moderate 0.88 (95% CI 0.82–0.95), severe 0.79 (95% CI 0.7–0.89), and extreme 0.68 (95% CI 0.58–0.79). Adjusted 30-day survival for the hypoxemia compared to normoxemia group was 0.83 (95% CI 0.74–0.92). Similar associations were seen in both out-of-hospital and in-hospital cardiac arrests. Conclusion In this nationwide observational study comprising both in- and out-of-hospital cardiac arrest patients, hyperoxemia at ICU admission was associated with lower 30-day survival.

To determine whether immigrant background and socioeconomic status were associated with increased risk to develop severe Coronavirus disease 2019 (COVID-19) requiring mechanical ventilation at the intensive care unit and to study their effects on 90-day mortality. Nationwide case–control study with personal-level data from the Swedish Intensive Care register linked with socioeconomic data from Statistics Sweden and comorbidity data from the national patient register. For each case of COVID-19 treated with mechanical ventilation at the intensive care unit (outcome), 10 population controls were matched for age, sex and area of residence. Logistic and Cox regression were used to study the association between the exposure (immigrant background, income and educational level) and 90-day mortality. In total, 4 921 cases and 49 210 controls were matched. In the adjusted model, the risk of severe COVID-19 was highest in individuals born in Asia (Odds ratio [OR] = 2.44, 95% confidence interval [CI] = 2.20–2.69), South America (OR = 2.34, 95% CI = 1.82–2.98) and Africa (OR = 2.11, 95% CI = 1.76–2.50). Post-secondary education was associated with a lower risk of severe COVID-19 (OR = 0.75, CI = 0.69–0.82) as was the highest (vs. lowest) income quintile (OR = 0.87, CI = 0.77–0.97). In the fully adjusted Cox-regression analysis birth region of Africa (OR 1.38, CI = 1.03–1.86) and high income (OR 0.75, CI 0.63–0.89) were associated with 90-day mortality. Immigrant background, educational level and income were independently associated with acquiring severe COVID-19 with need for mechanical ventilation.

Introduction Studies examining the factors linked to survival after out of hospital cardiac arrest (OHCA) have either aimed to describe the characteristics and outcomes of OHCA in different parts of the world, or focused on certain factors and whether they were associated with survival. Unfortunately, this approach does not measure how strong each factor is in predicting survival after OHCA. Aim To investigate the relative importance of 16 well-recognized factors in OHCA at the time point of ambulance arrival, and before any interventions or medications were given, by using a machine learning approach that implies building models directly from the data, and arranging those factors in order of importance in predicting survival. Methods Using a data-driven approach with a machine learning algorithm, we studied the relative importance of 16 factors assessed during the pre-hospital phase of OHCA. We examined 45,000 cases of OHCA between 2008 and 2016. Results Overall, the top five factors to predict survival in order of importance were: initial rhythm, age, early Cardiopulmonary Resuscitation (CPR, time to CPR and CPR before arrival of EMS), time from EMS dispatch until EMS arrival, and place of cardiac arrest. The largest difference in importance was noted between initial rhythm and the remaining predictors. A number of factors, including time of arrest and sex were of little importance. Conclusion Using machine learning, we confirm that the most important predictor of survival in OHCA is initial rhythm, followed by age, time to start of CPR, EMS response time and place of OHCA. Several factors traditionally viewed as important, e.g. sex, were of little importance.

ObjectivesIn a national perspective, to describe survival among patients found in ventricular fibrillation or pulseless ventricular tachycardia witnessed by a bystander and with a presumed cardiac aetiology and answer two principal questions: (1) what are the changes over time? and (2) which are the factors of importance?DesignObservational register study.SettingSweden.PatientsAll patients included in the Swedish Out of Hospital Cardiac Arrest Register between 1 January 1990 and 31 December 2009 who were found in bystander-witnessed ventricular fibrillation with a presumed cardiac aetiology.InterventionsBystander cardiopulmonary resuscitation (CPR) and defibrillation.Main outcome measuresSurvival to 1 month.ResultsIn all, 7187 patients fulfilled the set criteria. Age, place of out-of-hospital cardiac arrest (OHCA) and gender did not change. Bystander CPR increased from 46% to 73%; 95% CI for OR 1.060 to 1.081 per year. The median delay from collapse to defibrillation increased from 12 min to 14 min (p for trend 0.0004). Early survival increased from 28% to 45% (95% CI 1.044 to 1.065) and survival to 1 month increased from 12% to 23% (95% CI 1.058 to 1.086). Strong predictors of early and late survival were a short interval from collapse to defibrillation, bystander CPR, female gender and OHCA outside the home.ConclusionIn a long-term perspective in Sweden, survival to 1 month after ventricular fibrillation almost doubled. This was associated with a marked increase in bystander CPR. Strong predictors of outcome were a short delay to defibrillation, bystander CPR, female gender and place of collapse.

Background Reducing the time to treatment by means of cardiopulmonary resuscitation (CPR) and defibrillation is essential to increasing survival after cardiac arrest. A novel method of dispatching drones for delivery of automated external defibrillators (AEDs) to the site of a suspected out-of-hospital cardiac arrest (OHCA) has been shown to be feasible, with the potential to shorten response times compared with the emergency medical services. However, little is known of dispatchers’ experiences of using this novel methodology. Methods A qualitative semi-structured interview study with a phenomenological approach was used. Ten registered nurses employed at an emergency medical dispatch centre in Gothenburg, Sweden, were interviewed and the data was analysed by qualitative content analysis. The purpose was to explore dispatcher nurses’ experiences of deliveries of AEDs by drones in cases of suspected OHCA. Results Three categories were formed. Nurses expressed varying compliance to the telephone-assisted protocol for dispatch of AED-equipped drones. They experienced uncertainty as to how long would be an acceptable interruption from the CPR protocol in order to retrieve a drone-delivered AED. The majority experienced that collegial support was important. Technical support, routines and training need to be improved to further optimise action in cases of drone-delivered AEDs handled by dispatcher nurses. Conclusions Although telephone-assisted routines for drone dispatch in cases of OHCA were available, their use was rare. Registered nurses showed variable degrees of understanding of how to comply with these protocols. Collegial and technical support was considered important, alongside routines and training, which need to be improved to further support bystander use of drone-delivered AEDs. As the possibilities of using drones to deliver AEDs in cases of OHCA are explored more extensively globally, there is a good possibility that this study could be of benefit to other nations implementing similar methods. We present concrete aspects that are important to take into consideration when implementing this kind of methodology at dispatch centres.

ObjectivesThe objective of this study was to explore firefighters’ and police officers’ experiences of responding to out-of-hospital cardiac arrest (OHCA) in a dual dispatch programme.DesignA qualitative interview study with semi-structured, open-ended questions where critical incident technique (CIT) was used to collect recalled cardiac arrest situations from the participants’ narratives. The interviews where transcribed verbatim and analysed with inductive content analysis.SettingThe County of Stockholm, Sweden.ParticipantsPolice officers (n=10) and firefighters (n=12) participating in a dual dispatch programme with emergency medical services in case of suspected OHCA of cardiac or non-cardiac origin.ResultsAnalysis of 60 critical incidents was performed resulting in three consecutive time sequences (preparedness, managing the scene and the aftermath) with related categories, where first responders described the complexity of the cardiac arrest situation. Detailed information about the case and the location was crucial for the preparedness, and information deficits created stress, frustration and incorrect perceptions about the victim. The technical challenges of performing cardiopulmonary resuscitation and managing the airway was prominent and the need of regular team training and education in first aid was highlighted.ConclusionsParticipating in dual dispatch in case of suspected OHCA was described as a complex technical and emotional process by first responders. Providing case discussions and opportunities to give, and receive feedback about the case is a main task for the leadership in the organisations to diminish stress among personnel and to improve future OHCA missions.

BackgroundIn the last decade, there has been a rapid increase in the dissemination of automated external defibrillators (AEDs) for prehospital defibrillation of out-of-hospital cardiac arrest patients. The aim of this study was to study the association between different defibrillation strategies on survival rates over time in Copenhagen, Stockholm, Western Sweden and Amsterdam, and the hypothesis was that non-EMS defibrillation increased over time and was associated with increased survival.MethodsWe performed a retrospective analysis of four prospectively collected cohorts of out-of-hospital cardiac arrest patients between 2008 and 2013. Emergency medical service (EMS)-witnessed arrests were excluded.ResultsA total of 22 453 out-of-hospital cardiac arrest patients with known survival status were identified, of whom 2957 (13%) survived at least 30 days postresuscitation. Of all survivors with a known defibrillation status, 2289 (81%) were defibrillated, 1349 (59%) were defibrillated by EMS, 454 (20%) were defibrillated by a first responder AED and 429 (19%) were defibrillated by an onsite AED and 57 (2%) were unknown. The percentage of survivors defibrillated by first responder AEDs (from 13% in 2008 to 26% in 2013, p<0.001 for trend) and onsite AEDs (from 14% in 2008 to 30% in 2013, p<0.001 for trend) increased. The increased use of these non-EMS AEDs was associated with the increase in survival rate of patients with a shockable initial rhythm.ConclusionSurvivors of out-of-hospital cardiac arrest are increasingly defibrillated by non-EMS AEDs. This increase is primarily due to a large increase in the use of onsite AEDs as well as an increase in first-responder defibrillation over time. Non-EMS defibrillation accounted for at least part of the increase in survival rate of patients with a shockable initial rhythm.