Stay n’ Play or Scoop n’ Run for OHCA

October 13, 2020

Written by Kevin Stoffer

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For adults with atraumatic out-of-hospital-cardiac-arrest (OHCA), intra-arrest transport was associated with lower survival to discharge and less favorable neurological outcome compared to scene management.

Why does this matter?
We know that pre-hospital management of cardiac arrest saves lives, but how we manage these patients is difficult to study because of the heterogeneity of EMS practice in our country.  The optimal duration to manage OHCA on scene is unknown.

Should I stay or should I go?
This was a prospective cohort study of a North American consortium that included 43,000 adult patients with non-traumatic OHCA.  The primary outcome was survival to discharge in those who received intra-arrest transport compared to those who received scene resuscitation. The secondary outcome was neurologic status at discharge (Modified Rankin Score < 3 – slight disability or better).  This was a retrospective analysis of the large Resuscitation Outcomes Consortium database. They adjusted for confounders such as initial cardiac rhythm, EMS level of care, time to ROSC, location of patient, and resuscitation duration.  Because patients who do not achieve ROSC during scene resuscitation are often transported even after long resus duration, they used a time-matched propensity score to adjust for this bias.  Ultimately, they found scene resuscitation was associated with a significant increase in survival to discharge (8.5%) compared to intra-arrest transport (4%) and a favorable neurological outcome at discharge: 7.1% compared to 2.9%.  These results fuel the necessity for an RCT. Our EMS colleagues have the resources they need to care for these patients in the field, and we should design protocols allowing them to put their skills to use prior to transport. I would optimize my resuscitation on scene, with excellent compressions and early defibrillation before considering transport.

Source
Association of Intra-arrest Transport vs Continued On-Scene Resuscitation With Survival to Hospital Discharge Among Patients With Out-of-Hospital Cardiac Arrest. JAMA.2020;324(11):1058–1067. doi:10.1001/jama.2020.14185

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Reviewed by Clay Smith
Reviewer comment: This favors stay n’ play. Even with propensity matching, there is always potential for unrecognized confounders that may have influenced the decision to stay or to transport that biased the results.