Assessment of frontal EEG measurement in out-of-hospital cardiac arrest: a prospective observational feasibility study – study protocol

Extracorporeal Cardiopulmonary Resuscitation: Prehospital or In-Hospital Cannulation?

Resuscitation highlights in 2011

Search Strategy and Review Methods A structured literature search was conducted to identify publications addressing the early post-resuscitation phase following return of spontaneous circulation (ROSC) in patients with out-of-hospital cardiac arrest (OHCA), with particular focus on prehospital management and the interval preceding hospital handover. The search strategy was structured around four conceptual domains: (1) population – out-of-hospital cardiac arrest; (2) physiological state – return of spontaneous circulation; (3) setting – emergency medical services and prehospital care; and (4) processes of interest – early post-ROSC management, recurrent cardiac arrest (rearrest), monitoring, transport and hospital handover. Electronic searches were performed in PubMed/MEDLINE, Scopus and Web of Science Core Collection. Search queries combined controlled vocabulary (e.g. MeSH terms) and free-text terms related to OHCA, ROSC, emergency medical services and post-resuscitation processes including rearrest, monitoring, transport and hospital handover. Search strategies were iteratively refined to improve specificity for literature addressing early post-ROSC prehospital care and transport-related decision making. Searches were limited to publications in English published between 1990 and 2025. Detailed database queries are provided in the associated search strings document. Studies were eligible if they addressed adult patients with out-of-hospital cardiac arrest who achieved ROSC and described clinical, physiological or operational aspects of the prehospital phase preceding hospital handover. Publications examining rearrest, post-ROSC physiological instability, monitoring strategies, transport preparation, destination decisions, pre-notification or early post-resuscitation management in the EMS setting were considered relevant. Observational studies, registry analyses, clinical reviews, guideline documents and relevant methodological publications were eligible for inclusion. Studies focused exclusively on in-hospital cardiac arrest, paediatric populations or purely in-hospital post-resuscitation care without relevance to the prehospital phase were excluded. Titles and abstracts were screened independently by two reviewers to assess relevance to the research question. Full texts of potentially relevant publications were subsequently reviewed for eligibility. Disagreements were resolved by discussion and consensus. Included studies were synthesised using a structured narrative approach designed to integrate heterogeneous evidence relevant to the early post-ROSC phase in the prehospital environment. Studies were grouped according to thematic domains reflecting key aspects of care during the ROSC-to-handover interval, including physiological instability after ROSC, mechanisms and recognition of rearrest, monitoring and stabilisation strategies, operational traps during the post-resuscitation phase, preparation for transport, transport environment and destination decisions, and communication with receiving hospitals. Because the objective of the review was conceptual and integrative, the synthesis focused on identifying recurring physiological mechanisms, operational challenges and system-level considerations rather than performing quantitative pooling of results. Evidence was interpreted with attention to study design, EMS system characteristics and methodological limitations. This narrative synthesis aimed to develop an integrated conceptual framework describing the ROSC-to-handover interval as a distinct clinical–operational phase linking resuscitation and definitive post-cardiac arrest care. PubMed / MEDLINE search strategy (("Heart Arrest"[Mesh] OR "cardiac arrest"[tiab] OR "out-of-hospital cardiac arrest"[tiab] OR OHCA[tiab]) AND ("Return of Spontaneous Circulation"[Mesh] OR "return of spontaneous circulation"[tiab] OR ROSC[tiab]) AND ("Emergency Medical Services"[Mesh] OR prehospital[tiab] OR "pre-hospital"[tiab] OR EMS[tiab] OR "prehospital care"[tiab]) AND ("post-resuscitation"[tiab] OR "post cardiac arrest"[tiab] OR rearrest[tiab] OR "re-arrest"[tiab] OR transport[tiab] OR handover[tiab] OR destination[tiab] OR bypass[tiab])) Filters: English Scopus search strategy TITLE-ABS-KEY ( ( "out-of-hospital cardiac arrest" OR OHCA OR "cardiac arrest" ) AND ( "return of spontaneous circulation" OR ROSC ) AND ( prehospital OR "pre-hospital" OR "emergency medical services" OR EMS ) AND ( "post-resuscitation care" OR "post cardiac arrest care" OR rearrest OR "re-arrest" OR transport OR handover OR destination OR bypass ) ) AND ( LIMIT-TO ( LANGUAGE , "English" ) ) Web of Science search strategy TS=(("out-of-hospital cardiac arrest" OR OHCA OR "cardiac arrest") AND ("return of spontaneous circulation" OR ROSC) AND (prehospital OR "pre-hospital" OR "emergency medical services" OR EMS) AND ("post-resuscitation care" OR "post cardiac arrest care" OR rearrest OR "re-arrest" OR transport OR handover OR destination OR bypass)) Literature identification and screening The database search performed on xxxx XX, 2026 identified the following records: PubMed/MEDLINE (n = xxx ) Scopus (n = xxx ) Web of Science Core Collection (n = xxx) A total of xxxx records were identified across the three databases. After removal of duplicates, the remaining records were screened based on titles and abstracts to assess relevance to the research question. Potentially relevant articles were retrieved for full-text assessment. Publications were excluded if they focused exclusively on in-hospital post-resuscitation care, paediatric populations, or topics unrelated to the early post-ROSC phase in the prehospital environment. Studies addressing physiological stabilisation after ROSC, monitoring strategies, mechanisms of rearrest, transport preparation, destination decisions and hospital pre-notification were considered eligible for qualitative synthesis. The final set of included studies was used to inform the narrative synthesis and conceptual framework describing the ROSC-to-handover interval presented in the main manuscript.

BackgroundIndividuals with a low socioeconomic status (SES) may have a greater mortality rate from out of hospital cardiac arrest (OHCA) than those with a high SES. We explored whether SES disparities in OHCA mortality manifest in the incidence of OHCA, the chance of receiving bystander cardiopulmonary resuscitation (CPR) or in the chance of surviving an OHCA. We also studied whether sex and age differences exist in such SES disparities. MethodsThe Medline, Embase and Scopus databases were searched from 01-01-1993 until 31-01-2019. Studies utilising any study design or population were included. Studies were included if the exposure was SES of the OHCA victim or the OHCA location and the outcome was either OHCA incidence, CPR provision and/or survival rate after OHCA. Study selection and quality assessment were conducted by two reviewers independently. Descriptive data and measures of association were extracted, both in the total study population and in subgroups stratified by age and/or sex. This review was carried out following the PRISMA guidelines. ResultsOverall 32 studies were included. Twelve studies reported on OHCA incidence, thirteen on bystander CPR provision and fourteen on survival. Some evidence for SES differences was found in each identified stage. In all the studies on incidence, SES was measured over the area of the OHCA victims’ residence and was consistently associated with OHCA. In studies on bystander CPR, SES of the area in which the OHCA occurred was associated with bystander CPR, while evidence on individual SES was lacking. In studies on OHCA survival, SES of the victim measured at the individual level and SES of the area in which the OHCA occurred were associated, while SES of the victim, measured at the area of residence was not. Studies reporting age and sex differences in the SES trends were scarce. ConclusionSES disparities in OHCA mortality likely manifest in OHCA incidence, bystander CPR provision and survival rate after OHCA. However, there is a distinct lack of data on SES measured at the individual level and on differences within subgroups, e.g. by sex and age.

Effectiveness of Emergency Medical Services for Victims of Out-of-Hospital Cardiac Arrest: A Metaanalysis

The characteristics of an individual patient experiencing out-of-hospital cardiac arrest who recovered spontaneous circulation with the assistance of witnesses and paramedics were examined. The analysis of bystander cardiopulmonary resuscitation (CPR) and the professional first aid efforts of paramedics in the pre-hospital environment is pivotal to enhancing the survival rate of out-of-hospital cardiac arrest patients. The data used in this study were extracted from the Korea Centers for Disease Control and Prevention (KCDC) nationally recognized statistics, Acute Heart Failure big data survey. Out-of-hospital cardiac arrest (OHCA) customer data were collected from the Gangwon Fire Headquarters public information database as social management data. The data were analyzed using SPSS 24. The study's results emphasized the significance of offering basic CPR training to the public. This is evident from the fact that 90.5% of the first witnesses in the study performed CPR on OHCA patients, resulting in the recovery of spontaneous circulation (ROSC). The majority of patients with ROSC were male, with the highest age group being 41-50 years. Heart disease, hypertension, and diabetes were common medical conditions. The rate of witnessing cardiac arrest was high. Among the first witnesses, about 78.4% were of cardiac arrest incidents involving family members, co-workers, or acquaintances; 12.2% were on-duty medical healthcare personnel; and 9.5% were off-duty healthcare personnel. Cardiac arrest was treated in 83.8% of cases, with 90% of witnesses performing CPR. The percentage of witnesses that used an automated external defibrillator (AED) was 13.5%. In this study, the rates of ECG monitoring, CPR performance, and defibrillation performed by paramedics were high, but intravascular access and drug administration had a lower rate of performance. The time elapsed depended on the patient's physical fitness. The study found that paramedics had the highest CPC restoration rate in patients with cardiac arrest, followed by EMTs and nurses. Significant differences were observed in cerebral performance scores after care by these paramedics and nurses. To increase the performance of AEDs, more AEDs should be installed in public spaces so that the public can access them conveniently in cases of emergency. In addition, it is necessary to improve the quality of professional first aid physical activity services performed by first-class paramedics.

Background: Prolonged conventional cardiopulmonary resuscitation (C-CPR) is associated with a poor prognosis in out-of-hospital cardiac arrest (OHCA) patients. Extracorporeal cardiopulmonary resuscitation (E-CPR) has been utilized as a rescue strategy for patients with cardiac arrest unresponsive to C-CPR. However, the indication and optimal duration to switch from C-CPR to E-CPR are not well established. In addition, the opportunities to develop teamwork skills and expertise to mitigate risks are few. We thus developed the implementation protocol for the E-CPR simulation program, and investigated whether the faster deployment of extracorporeal membrane oxygenation (ECMO) improves the neurological outcome in patients with refractory OHCA. Methods: A total of 42 consecutive patients (age 58±16 years, male ratio 90%, and initial shockable rhythm 64%) received E-CPR (3% of OHCA) during the study period. Among them, 32 (76%) were deployed ECMO during the pre-intervention time period (Pre: from January 2012 to September 2017), whereas 10 (24%) were deployed during the post-intervention time period (Post: October 2017 to May 2019). We compared the door to E-CPR time, collapse to E-CPR time, 30-day mortality, and favorable neurological outcome (Cerebral Performance Categories 1, 2) between the two periods. Results: There was no significant difference in age, the rates of male sex and shockable rhythm, and the time form collapse to emergency room admission between the two periods. The door to E-CPR time and the collapse to E-CPR time were significantly shorter in the post-intervention period compared to the pre-intervention period (Pre: 39 min [IQR; 30-50] vs. Post: 29 min [IQR; 22-31]; P=0.007, Pre: 76 min [IQR; 58-87] vs. Post: 59 min [IQR; 44-68]; P=0.02, respectively). The 30-day mortality was similar between the two periods (Pre: 88% vs. Post: 80%; P=0.6). In contrast, the rate of favorable neurological outcome at the time of discharge was significantly higher in post-intervention period (Pre: 0% vs. Post: 20%; P=0.01) compared to the pre-intervention period. Conclusion: A comprehensive simulation-based training for E-CPR seems to improve the neurological outcome in patients with refractory OHCA patients.

Introduction: Lay rescuers have a crucial role in successful cardiopulmonary resuscitation (CPR), specifically the first three links in the chain of survival, for out-of-hospital cardiac arrest (OHCA). However, randomized controlled trials on the priority of emergency call (Call first) versus bystander CPR (CPR first) do not exist, and comparative data are very limited. We aimed to assess the association between the priority of bystander’s action (Call first vs. CPR first) and neurologic outcome after OHCA. Methods: This nationwide population-based study of patients who experienced OHCA from January 2005 to December 2014 was based on the data from the Japanese government-managed registry of OHCA. Patients provided bystander’s action (both emergency call and bystander CPR) within 1 minute of witness were included, and Call first strategy was compared with CPR first strategy. The primary outcome was one-month neurologically favorable survival, defined as a Glasgow-Pittsburgh cerebral performance category (CPC) score of 1(good performance) or 2(moderate disability). The secondary outcomes were prehospital return of spontaneous circulation (ROSC) and one-month overall survival. Results: A total of 25,840 patients were included; 4,430 (17.1%) were treated with Call first approach, and 21,410 (82.9%) were treated with CPR first approach. Among total cohort, 2,696 (10.4%) survived with neurologically favorable status one month after OHCA. In the propensity score-matched cohort, one-month neurologically favorable survival was lower among Call first group compared with CPR first group: 364 of 4,430 patients (8.2%) vs. 457 of 4,430 patients (10.3%), respectively (Risk ratio [RR], 0.80; 95% confidence interval [CI], 0.70-0.91). Similar associations were observed for one-month overall survival (RR, 0.90; 95%CI, 0.82-0.99), although there were no significant differences in prehospital ROSC (RR, 0.94; 95%CI, 0.86-1.02) between the Call first and CPR first groups. In subgroup analyses, the association between delayed bystander CPR and worse neurological outcome did not change regardless of subgroup characteristics. Conclusions: In witnessed OHCA, Call first approach was associated with a decreased chance of one-month neurologically favorable survival compared with CPR first approach. These observational findings warrant a randomized clinical trial to determine the priority of emergency call or bystander CPR for OHCA.

Recognising out-of-hospital cardiac arrest during emergency calls increases bystander cardiopulmonary resuscitation and survival

Exploratory Observational Study of Extracorporeal Cardiopulmonary Resuscitation for Nonshockable Out-Of-Hospital Cardiac Arrest Occurring After an Emergency Medical Services Arrival: SOS-KANTO 2012 Study Report.

Extra corporeal membrane oxygenation (ECMO) for refractory out-of-hospital cardiac arrest (OHCA) has been shown to improve outcome in many Western countries. There are no reports of ECMO being used to support OHCA in India till date. We report a case of a young man who developed cardiac arrest (CA) while driving and was given bystander cardiac massage. He was brought to tertiary care center where an ECMO was utilized for refractory CA. The patient subsequently underwent emergency coronary artery stenting and was weaned off ECMO and ventilation. We discuss the case and highlight the role of bystander cardiopulmonary resuscitation.

FOR MORE THAN A DECADE, CARDIOPULMONARY RESUScitation (CPR) using only chest compressions, forgoing ventilations by rescue breathing, has been described as an option in the out-of-hospital management of sudden cardiac arrest when bystanders are unwilling or unable to provide standard CPR that combines chest compressions with rescue breathing. The “Guidelines 2005” CPR standards promulgated by the American Heart Association (AHA) and the International Liaison Committee on Resuscitation (ILCOR) indicate that “the best method of CPR is compressions coordinated with ventilations.” However, the guidelines also note that laypersons who are unable or unwilling to provide rescue breaths should be encouraged to provide compressiononly CPR to individuals experiencing out-of-hospital cardiac arrest. This recommendation followed a 1997 AHA science statement that was the first document to propose compression-only CPR as a reasonable alternative to standard CPR by bystanders. Several fairly compelling theoretical arguments support the concept of compression-only CPR. First, it seems likely that compression-only CPR is easier to teach and remember than standard CPR, particularly for those who do not work in health care professions. Second, it has been postulated that bystanders may prefer to avoid mouth-to-mouth contact with persons who sustain cardiac arrest, particularly when those persons are strangers. However, in a study of actual bystanders of out-ofhospital cardiac arrest, very few (1.1%) mentioned reluctance to perform rescue breathing, and none reported fear of contracting infection. Third, and perhaps most compelling, an increasing body of evidence suggests that interruptions in chest compressions, even for such seemingly important interventions as providing artificial ventilation, are detrimental. Forward flow of blood ceases very soon after chest compressions are halted, and several compressions are needed to reestablish perfusion when compressions are resumed. The “push hard, push fast, don’t stop” mantra of current CPR teaching is designed to reinforce the need for minimal interruptions in chest compressions to maintain some degree of perfusion to the vital organs until more definitive therapy (such as defibrillation) can be delivered. Despite these theoretical advantages, most animal studies and human trials comparing standard CPR and compression-only CPR have reported similar outcomes for the 2 techniques; data showing a convincing survival advantage to the compression-only technique are lacking. Additionally, most of the existing human data are from observational studies, with few experimental trials in the published literature. Randomization is one of several significant barriers to performing these trials, particularly when examining CPR provided by bystanders who witness the collapse and provide immediate intervention while emergency medical services (EMS) personnel are summoned. Although it is possible to randomize the type of CPR provided by EMS personnel responding to an out-of-hospital cardiac arrest, or by a team responding to an in-hospital cardiac arrest, it is nearly impossible to randomize the type of CPR provided by a bystander at the scene of an out-of-hospital cardiac arrest. One elegant solution to this problem was used in a 2000 study by Hallstrom et al and in 2 recently published studies. Randomization was performed by 9-1-1 dispatchers for callers who were willing to perform CPR but did not know how to do so. In each study, the survival rate for patients who experienced out-of-hospital cardiac arrest and received dispatcher-assisted standard CPR was similar to that for those with cardiac arrest who received dispatcherassisted compression-only CPR, despite data showing that chest compressions are delivered sooner when the dispatcher omits the ventilation instructions, providing another theoretical benefit to compression-only CPR. However, in these 3 studies, no CPR was delivered from the time the patient collapsed until the time the caller recognized the emergency, reached 9-1-1, completed the questions in the dispatcher’s algorithm, was randomized by the dispatcher, and received CPR instructions. This no-perfusion time, typically longer than 2 minutes, may have contributed to the findings.

Background: Gender differences of outcomes of out-of-hospital cardiac arrest (OHCA) were reported in previous studies and still remains uncertainty. Furthermore, gender disparities in in-hospital management are not well studied. Hypothesis: We hypothesized there is differences in in-hospital management in OHCA patients by gender in Korea. Method: This is an observational study using Korean Cardiac Arrest Research Consortium (KoCARC) data. Adult (age over 18 years) OHCA patients from October 2015 to June 2020 were included. The main variable of interest was gender. Primary outcomes were whether in-hospital managements such as coronary angiography (CAG), percutaneous coronary intervention (PCI), target temperature management (TTM), and extracorporeal membrane oxygenation (ECMO) were performed. Secondary outcomes were clinical outcomes such as survival to admission, survival to discharge, and good neurologic outcome (cerebral performance category 1 or 2) at discharge. The propensity score matching (PSM) method was performed to minimize differences in baselines demographics and characteristics. Results: Total 8,177 OHCA patients were enrolled. After PSM, 6564 patients (female: 2782, male: 2782) were obtained. In unmatched cohort, female patients were less likely receive CAG, PCI, TTM, ECMO and less likely to survive to admit, survive to discharge, and discharge as good neurologic outcome. In PSM cohort, female patients were less likely to receive CAG, PCI than male (179 (6.4%) vs 252 (9.1%), p<0.001 and 54 (1.9%) vs 104 (8.2%), p<0.001, respectively). The proportion of TTM, ECMO, and clinical outcomes were not statistically different among gender. Conclusions: CAG, PCI were less likely to performed in female OHCA patients. Further studies are needed for gender disparities in in-hospital management of OHCA patients.

Objective To investigate the epidemiological features of out-of-hospital cardiac arrest (OHCA) in Zhejiang and to analysis factors associated with outcomes for providing evidence on improving the success rate of cardiopulmonary resuscitation (CPR). Methods Clinical data of 493 patients with OHCA collected from the emergency department (ED) of Zhejiang Provincial People's Hospital, Ningbo Emergency Medical Service Center and Shaoxing Emergency Medical Service Center from January 2012 to August 2016 were analyzed retrospectively. All the data were recorded following the Utstein style included causes of arrest, location of arrest, first arrest rhythm, witnessed by bystanders, bystander CPR, pre-hospital defibrillation, pre-hospital intubation, pre-hospital epinephrine administration, emergency medical services (EMS) response time, return of spontaneous circulation (ROSC) at scene/enroute, ROSC at ED, admission to hospital, survival to hospital discharge and neurological outcomes at discharge. Factors associated with 30 days survival rate of patients with OHCA were analyzed. Results 493 patients were enrolled, of whom 342 were male and 151 were female. The average age was (58.8±21.4) years. The causes of arrests consisted of cardiac etiology (219 cases), trauma (155 cases), respiratory disease (22 cases), drowning (19 cases), electrocution (8 cases) and others (70 cases). Most of the events occurred at home (65.1%) and public places (22.7%). 55.2% patients were witnessed by bystanders while bystander CPR was performed in only 2.6% cases. Asystole was the predominant rhythm (78.7%) observed by the ambulance crew at the arrest site while only 5.5% first arrest rhythms were ventricular fibrillation/ventricular tachycardia (VF/VT). Only 6.9% patients underwent pre-hospital defibrillation. Pre-hospital intubations were attempted in 16.4% patients. Epinephrine was administered in 56.4% patients at scene or in ambulances. EMS response time was (13.6±8.0) minutes. 4.5% patients had ROSC at scene/enroute and 7.7% had ROSC at ED. Only 9.7% patients were admitted to hospital and 1.2% discharged alive. 0.8% patients were still in hospital on 30th day. The 30-day survival rate was 2.0% (10/493) and only 0.8% patients had neurologically favorable survivals [with the cerebral performance category (CPC) score of 1 or 2]. Witnessed by bystanders (3.31% vs. 0.45%), VF/VT as the first arrest rhythm (7.41% vs. 1.72%), bystander CPR (15.38% vs. 1.67%), pre-hospital defibrillation (8.82% vs. 1.53%) and EMS response time < 10 minutes (3.57% vs. 0.74%) could improve 30-day survival rate of OHCA significantly (all P < 0.05). Conclusion Resuscitation survival of OHCA in Zhejiang province was unsatisfactory. Improvements are required in series aspects of OHCA survival chain. Key words: Out-of-hospital cardiac arrest; Cardiopulmonary resuscitation; Epidemiology; Outcome; Emergency medical services response time

LONG-TERM MORTALITY, READMISSION AND FUNCTIONAL OUTCOMES AMONG HOSPITAL SURVIVORS OF OUT-OF-HOSPITAL CARDIAC ARREST