DÄ internationalArchive51-52/2020Survival Following Lay Resuscitation

Original article

Survival Following Lay Resuscitation

An analysis of data from the German Resuscitation Registry (Deutsches Reanimationsregister)

Dtsch Arztebl Int 2020; 117: 871-7. DOI: 10.3238/arztebl.2020.0871

Gässler, H; Helm, M; Hossfeld, B; Fischer, M

Background: Resuscitation by laypersons is important in bridging the time between the occurrence of an out-of-hospital cardiac arrest (OHCA) and the arrival of emergency rescue service personnel. Depending on the reason for the cardiac arrest, however, the effectiveness of chest compressions is uncertain. The aim of this study was to explore the impact of lay resuscitation on survival following OHCA of different causes.

Methods: The data set for analysis comprised all cases of cardiac arrest before the arrival of emergency rescue service personnel that were fully documented in the German Resuscitation Registry in the period 2007–2019. The following endpoints related to resuscitation by bystanders were evaluated—separately for each cause—descriptively and by means of multivariate logistic regression analysis: return of spontaneous circulation (ROSC), 30 days’ survival/discharged alive from the hospital, and good neurological function at discharge.

Results: Altogether, 40 604 cases of cardiac arrest were included. Resuscitation by laypersons was carried out in 35.1% of these cases. The rate of ROSC was statistically significantly higher after lay resuscitation for OHCA caused by cardiac events, drowning, intoxication, or central nervous system disorders (overall 48.1% versus 41.0%). For all causes—with the exception of trauma/bleeding to death and sepsis—the endpoint 30 days’ survival/discharged alive was better with lay resuscitation (overall 17.0% versus 9.5%). In multivariate regression analysis, lay resuscitation was associated with improvement of the endpoint 30 days’ survival/discharged alive only for OHCA caused by cardiac events (odds ratio [OR] 1.16) or intoxication (OR 1.81). For all other causes—except hypoxia—lay resuscitation tended to yield better results. Neurological function at discharge was also significantly better (overall 11.5% versus 6.1%) after lay resuscitation for OHCA of all causes except trauma/bleeding to death, hypoxia, and sepsis.

Conclusion: Resuscitation by laypersons is associated with an improved result regarding the endpoint 30 days’ survival/discharged alive in cases of OHCA caused by cardiac events and intoxication. These two groups account for 81% of the resuscitation patients in the study. Because there was also a tendency towards higher survival rates following OHCA of other causes (except hypoxia), laypersons should continue to be encouraged to attempt resuscitation in all cases of OHCA, whatever the cause.

LNSLNS

Out-of-hospital cardiac arrest (OHCA) plays an important role in the work of the emergency rescue services. According to recent studies, the annual incidence of OHCA in Europe is around 84.0–87.4 cases/100 000 inhabitants (1, 2). Gräsner et al. (1) evaluated OHCA and found that cardiopulmonary resuscitation (CPR) was carried out by laypersons or emergency rescue service personnel in approximately 49 cases/100 000 inhabitants in the European Union. The most recent annual report of the German Resuscitation Registry (GRR; Deutsches Reanimationsregister) states that the incidence of prehospital resuscitation was 62.6/100 000 inhabitants in Germany in 2019 (3). Despite intensive scientific efforts and public information campaigns in several countries, the survival rate following OHCA is still only 10–13% (1, 3, 4).

Crucial factors for survival after OHCA are early initiation and high-quality performance of basic resuscitation measures (5). Lay resuscitation seems to have an important role in this regard. Not only is it associated with better 30-day survival (6), but a positive effect can still be demonstrated a year later (7). In this respect, it appears relevant that lay resuscitation lengthens the time window for successful defibrillation (8, 9). A further essential component of basic resuscitation measures is the use of automatic external defibrillators (AED), which in recent years have been installed in many public buildings and other places where people congregate. The use of AED by bystanders in OHCA observed to occur in public spaces is associated with significant improvement of both the hospital discharge rate and neurological function following discharge. (Please note that throughout this article, “significant” means statistically significant.)

Although the resuscitation guidelines of the European Resuscitation Council (ERC) recommend chest compressions in cardiac arrest (CA) regardless of the cause, a uniform effect, e.g., in CA associated with trauma, is viewed as unlikely (11). The value of lay resuscitation with chest compressions in CA of non-cardiac origin is therefore uncertain. To the best of our knowledge, no systematic studies on the influence of lay resuscitation depending on the cause of CA have been published.

Our study group has shown that survival and the quality of neurological function following OHCA vary widely depending on the cause of the CA (4). This indicates that the measures comprising CPR are not uniformly successful in CA of different origins. We therefore designed this study to explore, on the basis of data from a large national resuscitation registry, the association between lay resuscitation and survival in OHCA of different causes.

Method

Prospectively collected data were retrospectively analyzed. The GRR data were provided in anonymized form, so that no patient or emergency rescue service center could be identified. The study was approved by the ethics committee of Ulm University (no. 138/19) and conducted in accordance with the tenets of the Declaration of Helsinki 2013.

This study was based on data from all prehospital resuscitations in the period 2007–2019 documented in the GRR with full detail of the primary care module and—in the event of hospital admission—complete information on the further clinical treatment module with data on patient outcome. To increase the data quality, analysis was restricted to the reference centers of the GRR (for detail, see the eMethods) (3). Cases in which OHCA occurred after the arrival of emergency rescue service personnel were excluded.

The data sets included for analysis were sorted by the cause of OHCA documented in the primary care module. Related causes that were practically impossible to distinguish from one another in the out-of-hospital setting were amalgamated (Table 1). In accordance with the Utstein Resuscitation Registry templates for OHCA, cases of unknown or other cause were assigned to the category of cardiac events (12). Separating the OHCA by cause, we began by exploring the associations between lay resuscitation and the following endpoints:

  • Return of spontaneous circulation (ROSC)
  • Survival for 30 days or discharge from the hospital alive
  • Good neurological function at discharge (cerebral performance category [CPC] 1/2)
Documented causes of cardiac arrest in the German Resuscitation Registry and classification for analysis in this study
Table 1
Documented causes of cardiac arrest in the German Resuscitation Registry and classification for analysis in this study

We then used multivariate binary logistic regression analysis to ascertain the effect of lay resuscitation on the endpoint 30 days’ survival/discharged alive—adjusting for previously identified confounders (for details see eMethods) (13).

The statistical analyses were carried out with the aid of IBM SPSS Statistics, Version 24. Categorical variables were evaluated using the chi-squared test, while the results of multivariate binary logistic regression analysis were expressed as odds ratios (OR) with 95% confidence interval. A p-value < 0.05 was considered to show a statistically significant difference.

Extensive description of the data acquisition with information about the documented cause and details of data evaluation and statistical analysis can be found in the eMethods.

Results

In the period 2007–2019, a total of 43 905 OHCA were fully documented in the GRR, observing the criteria for reference centers. Following exclusion of the cases in which the OHCA only occurred after arrival of the emergency rescue services, 40 604 data sets were included for analysis.

Lay resuscitation took place in 35.1% of cases, and in 1.4% an AED was used. Patients resuscitated by bystanders were younger, more likely to be male, and the cardiac arrest was more likely to be an observed event. These patients were significantly more likely to have a cardiac rhythm amenable to defibrillation when emergency rescue services personnel arrived, had a significantly higher ROSC rate, and their 30-day survival rate was almost twice as high. Patients resuscitated by laypersons were also almost twice as likely to be discharged with good neurological function, defined as CPC 1/2 (Table 2).

Analysis of data from the German Resuscitation Registry, 2007–2019 *1
Table 2
Analysis of data from the German Resuscitation Registry, 2007–2019 *1

With regard to cause, the rate of lay resuscitation was highest for drowning and lowest for trauma/ bleeding to death. Significantly higher ROSC rates following lay resuscitation were seen for cardiac origin, drowning, intoxication, and central nervous system disorders. The endpoint 30 days’ survival/discharged alive was significantly higher after lay resuscitation for all causes except trauma/bleeding to death and sepsis.

After adjusting for all potential confounders, multivariate logistic regression analysis revealed a significantly higher survival rate following lay resuscitation for the whole study population, for cardiac origin, and for intoxication. For all other causes—with the exception of hypoxia—there was a tendency towards better survival after lay resuscitation. Only five patients survived OHCA caused by sepsis, too small a group to enable regression analysis (Figure).

Analysis of data from the German Resuscitation Registry, 2007–2019
Figure
Analysis of data from the German Resuscitation Registry, 2007–2019

Discussion

The study presented here was the first to explore the associations between lay resuscitation and both survival following OHCA and neurological recovery, related to the cause as diagnosed by the attending emergency physician. For certain causes, the endpoint 30 days’ survival/discharged alive was significantly better after lay resuscitation. Moreover, the proportion of patients discharged from the hospital with good neurological function is almost twice as high after lay resuscitation.

The data analyzed in this study came from the GRR. At the time of the study period, the registry received data from emergency rescue services covering areas of Germany with a total population of around 27 million. Because participation was voluntary, it can only be assumed that the sample is representative; however, earlier analyses of GRR data demonstrated comparability with other registry studies that partly included patients from the whole country (1, 4, 14).

The average lay resuscitation rate during the study period was 35.1%. This figure has risen steadily in recent years, reaching 42.1% by 2019 (3). Despite this increase, the rate of lay resuscitation in Germany is below the European average. A Europe-wide investigation of resuscitations that was performed as part of the EuReCa TWO study in 2017 found an average rate of 58% with a peak of 82% (15). The type of resuscitation carried out by bystanders seems to be associated with survival following OHCA. The survival rate was 14% for chest compressions with mouth-to-mouth resuscitation, significantly higher than the 8% found for chest compressions alone (15).

A positive effect between performance of lay resuscitation following OHCA and both survival of the event and neurological function at discharge was found by Bürger et al. in a study on the effect of the time between OHCA and the arrival of emergency rescue service personnel (5). However, the study adjusted only for cardiac causes in the multivariate analysis.

The largest category of OHCA in our study was “cardiac, other, and unknown,” accounting for 79.1% of the total. The analysis showed a significant benefit of lay resuscitation in this group, even after adjusting for potential influencing factors. Similar findings had already been made in a number of earlier studies, with regard to both 30-day survival (5, 6) and 1-year survival (7), so the result was not surprising. However, the OR found in our study was 1.16, showing a much less pronounced benefit of lay resuscitation than found in the study by Hasselqvist-Ax et al. (OR 2,94) (6). Assuming that our sample was representative, and with an estimated 52 000 out-of-hospital resuscitations, this would nevertheless mean that consistent implementation of lay resuscitation could result in the survival of 400 more patients in Germany each year after OHCA. Barnard et al. had similar findings: although in their study lay resuscitation had no impact on the rate of hospital admission, nevertheless significantly more patients resuscitated by bystanders were discharged alive (16). As a possible reason, the authors assumed that the main cause of death after admission could have been secondary brain damage owing to the longer time without CPR, while ROSC could still be attained because of the somewhat better tolerance of ischemia.

Lay resuscitation also had a significant survival benefit in OHCA due to intoxication. Here the adjusted effect was even higher, with an OR of 1.81. It may be that the cardiac arrest in intoxication is often due to respiratory arrest, which at an early stage is amenable to treatment with CPR. In contrast to OHCA caused by hypoxia due to a pulmonary disorder, in cases of intoxication there is usually no relevant disturbance of gas exchange. This would explain why—after adjusting for potential influencing factors— lay resuscitation is of no benefit in hypoxia-related OHCA, as seen in this study and described in an earlier publication (17).

Our study shows that the survival rate following cardiac arrest caused by drowning is twice as high with lay resuscitation; after adjustment, however, this effect is not significant. The patients resuscitated by bystanders were much younger. Without lay resuscitation the time before CPR was 18 min. The lack of benefit following adjustment could be explained by the presence of a pathomechanism comparable to hypoxia, with impairment of gas exchange decreasing the usefulness of lay resuscitation. This would be in accordance with the findings of a study in which the use of chest compressions together with addition of mouth-to-mouth resuscitation achieved no improvement in neurological outcome versus chest compressions alone (18). However, taking into account the tendency we found towards a benefit of lay resuscitation, with an OR of 1.72 and a wide confidence interval, it seems more likely that the number of cases (205 patients) is too low to permit statistically significant results. A number of studies published in the past 5 years, partly with much higher case numbers, demonstrated a significant benefit of lay resuscitation in drowned patients (19, 20, 21), albeit partly with extremely low survival rates (0.4% versus 0.8%) (21).

In OHCA caused by central nervous system disorders (ischemic and hemorrhagic apoplexy, subarachnoid hemorrhage, basilar artery thrombosis), we found no correlation of lay resuscitation with improvement of the endpoint 30 days’ survival/discharged alive. In this case the limiting factor for survival is not the successful restoration of circulation but the severity of the brain injury, which is ultimately what leads to death. Studies on cardiac arrest owing to subarachnoid hemorrhage showed highly elevated cerebral pressure in initial survivors, and in one study this led to brain death in 46% of cases (22, 23).

Because the number of survivors of OHCA due to sepsis was small in our study, we did not carry out regression analysis on the effect of lay resuscitation. However, the outcome was much worse than that for the sample as a whole (survival rate 3.0% versus 8.5%). The reason for this may well be that these patients often have septic cardiomyopathy and/or septic multiple organ failure, severely reducing the chance of successful treatment (24).

Trauma-associated OHCA had both the lowest ROSC rate and the lowest 30-day survival rate in our study, independent of whether lay resuscitation was carried out. These low survival rates have been described several times before (4, 25, 26, 27), and are understandable in view of the fact that around 85% of these patients have injuries incompatible with survival (28). Nevertheless, there remains a proportion of around 15% of patients in whom survival would be possible or even probable (28). To achieve this, however, the underlying causes of the cardiac arrest must be eliminated swiftly and decisively. Algorithms for this purpose have been published by various groups (29, 30, 31) and since 2015 have formed part of the ERC resuscitation guidelines (11). Because a layperson has no means of treating these causes, it seems understandable that lay resuscitation in this group of patients is not associated with significantly better survival.

Limitations

As is usually the case in retrospective analyses, the results must be interpreted cautiously with regard to causality. In this review, the prospective data acquisition and the analysis with the aid of multivariate logistic regression, adjusting for relevant confounders, help to reduce potential sources of error. Nevertheless, it cannot be excluded that other, unconsidered factors might influence the results. For ethical and logistical reasons, a randomized or blinded prospective design does not come into question for a study on this topic.

A further limitation is the validity of the documented causes of OHCA on which the analysis of the data was based. In the case of hospital admission and subsequent diagnostic evaluation, the cause entered in the registry by the attending emergency physician is most likely correct, because the emergency physician and hospital staff have the opportunity to discuss the underlying cause later, at which time the registry entry can be confirmed or corrected (by the emergency physician: the hospital cannot alter the cause documented in the registry’s primary care data set).

If the patient dies before arrival of the emergency physician, the latter has to determine the underlying cause of cardiac arrest on the basis of medical history, symptoms, and the known diagnostic details. It is not possible to use an algorithm for diagnosis following cardiac arrest, as proposed for example by Chan et al., owing to the lack of opportunity for diagnostic investigation at the location of the event (32). To our knowledge, there have been no systematic studies of the accuracy of diagnosis in these circumstances. Kürkciyan et al., however, showed that in initially successfully resuscitated patients the diagnosis made in the shock room, taking account of the patient’s medical history and symptoms, agreed with the clinical diagnosis in 83% of cases (33). These findings suggest that the quality of the data used in this study was not essentially affected by the fact that the cause was determined by the emergency physician at the place of deployment. Furthermore, to increase the validity of the documentation in this respect, causes that are difficult to differentiate in the out-of-hospital setting, such as trauma/bleeding to death or intracranial hemorrhage/apoplexy/subarachnoid hemorrhage, were amalgamated for analysis (Table 1).

Summary

Overall, a significant positive association was found between lay resuscitation and 30-day survival for OHCA caused by cardiac events or intoxication, corresponding to 81% of the cases analyzed. For other causes—with the exception of hypoxia—there was also a tendency towards a positive effect of resuscitation by bystanders; however, the differences were not statistically significant on multivariate analysis. Here, treatment of the underlying cause in the context of extended resuscitation measures seems more urgent. No negative effects of lay resuscitation are discernable, however, so—to keep the algorithm simple—resuscitation by laypersons should continue to be recommended and performed, regardless of the cause of cardiac arrest.

Conflict of interest statement
Prof. Fischer is a member of the organizing committee of the German Resuscitation Registry.

The remaining authors declare that no conflict of interest exists.

Manuscript received on 10 March 2020, revised version accepted on
3 August 2020

Translated from the original German by David Roseveare

Corresponding author
Dr. med. Holger Gässler
Bundeswehrkrankenhaus Ulm
Klinik für Anästhesiologie, Intensivmedizin,
Notfallmedizin und Schmerztherapie
Oberer Eselsberg 40, 89081 Ulm, Germany
holgergaessler@bundeswehr.org
Cite this as:
Gässler H, Helm M, Hossfeld B, Fischer M: Survival following lay resuscitation—an analysis of data from the German Resuscitation Registry (Deutsches Reanimationsregister). Dtsch Arztebl Int 2020; 117: 871–7. DOI: 10.3238/arztebl.2020.0871

Supplementary material

eMethods:
www.aerzteblatt-international.de/20m0871

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Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine, and Pain Therapy, German Armed Forces Hospital Ulm: Dr. med. Holger Gässler, Prof. Dr. med. Matthias Helm, Dr. med. Björn Hossfeld
Department of Anesthesiology and Intensive Care Medicine, Alb-Fils Hospitals, Göppingen:
Prof. Dr. med. Matthias Fischer
Analysis of data from the German Resuscitation Registry, 2007–2019
Figure
Analysis of data from the German Resuscitation Registry, 2007–2019
Documented causes of cardiac arrest in the German Resuscitation Registry and classification for analysis in this study
Table 1
Documented causes of cardiac arrest in the German Resuscitation Registry and classification for analysis in this study
Analysis of data from the German Resuscitation Registry, 2007–2019 *1
Table 2
Analysis of data from the German Resuscitation Registry, 2007–2019 *1
1.Gräsner JT, Lefering R, Koster RW, et al.: EuReCa ONE—27 Nations, ONE Europe, ONE Registry. A prospective one month analysis of out-of-hospital cardiac arrest outcomes in 27 countries in Europe. Resuscitation 2016; 105: 188–95 MEDLINE
2.Berdowski J, Berg RA, Tijssen JG, Koster RW: Global incidences of out-of-hospital cardiac arrest and survival rates: systematic review of 67 prospective studies. Resuscitation 2010; 81: 1479–87 MEDLINE CrossRef
3.Fischer M, Wnent J, Gräsner JT, et al.: Jahresbericht des Deutschen Reanimationsregisters – Außerklinische Reanimation 2019. Anästh Intensivmed 2020; 61: V89–93.
4.Gässler H, Fischer M, Wnent J, Seewald S, Helm M: Outcome after pre-hospital cardiac arrest in accordance with underlying cause. Resuscitation 2019; 138: 36–41 CrossRef MEDLINE
5.Bürger A, Wnent J, Bohn A, et al.: The effect of ambulance response time on survival following out-of-hospital cardiac arrest. An analysis from the German resuscitation registry. Dtsch Ärztebl Int 2018; 115: 541–8 VOLLTEXT
6.Hasselqvist-Ax I, Riva G, Herlitz J, et al.: Early cardiopulmonary resuscitation in out-of-hospital cardiac arrest. N Engl J Med 2015; 372: 2307–15 MEDLINE
7.Kragholm K, Wissenberg M, Mortensen RN, et al.: Bystander efforts and 1-year-outcome in out-of-hospital cardiac arrest. N Engl J Med 2017; 376: 1737–47 MEDLINE CrossRef
8.Waalewijn RA, Nijpels MA, Tijssen JG, Koster RW: Prevention of deterioration of ventricular fibrillation by basic life support during out-of-hospital cardiac arrest. Resuscitation 2002; 54: 31–6 CrossRef MEDLINE
9.Christenson J, Andrusiek D, Everson-Stewart S, et al.: Chest compression fraction determines survival in patients with out-of-hospital ventricular fibrillation. Circulation 2009; 120: 1241–7 MEDLINE PubMed Central CrossRef
10.Pollack RA, Brown SP, Rea T, et al.: Impact of bystander automated external defibrillator use on survival and functional outcomes in shockable observed public cardiac arrests. Circulation 2018; 137: 2104–13 MEDLINE PubMed Central CrossRef
11.Truhlár A, Deakin CD, Soar J, et al.: European Resuscitation Council Guidelines for Resuscitation 2015. Section 4. Cardiac arrest in special circumstances. Resuscitation 2015; 95: 148–201 MEDLIN CrossRef
12.Perkins GD, Jacobs IG, Nadkarni VM, et al.: Cardiac arrest and cardiopulmonary resuscitation outcome reports: update of the utstein Resuscitation Registry Templates for out-of-hospital cardiac arrest. Resuscitation2015; 96: 328–40 MEDLINE CrossRef
13.Gräsner JT, Meybohm P, Lefering R, et al.: ROSC after cardiac arrest – the RACA score to predict outcome after out-of-hospital cardiac arrest. Eur Heart J 2011; 32: 1649–56 MEDLINE CrossRef
14.Gräsner JT, Seewald S, Bohn A, et al.: Deutsches Reanimationsregister: Wissenschaft und Reanimationsforschung. Anaesthesist 2014; 63: 470–6 MEDLINE CrossRef
15.Gräsner JT, Wnent J, Herlitz J, et al.: Survival after out-of-hospital cardiac arrest in Europ—results of the EuReCa TWO study. Resuscitation 2020; 148: 218–26 MEDLINE CrossRef
16.Barnard EBG, Sandbach DD, Nicholls TL, Wilson AW, Ari Ercole A: Prehospital determinants of successful resuscitation after traumatic and non-traumatic out-of-hospital cardiac arrest. Emerg Med J 2019; 36: 333–9 MEDLINE PubMed Central CrossRef
17.Fukuda T, Ohashi-Fukuda N, Kondo Y, Sera T, Yahagi N: Effect of rescue breathing by lay rescuers for out-of-hospital cardiac arrest caused by respiratory disease: a nationwide, population-based, propensity score-matched study. Intern Emerg Med 2017; 12: 493–501 MEDLINE CrossRef
18.Fukuda T, Ohashi-Fukuda N, Hayashida K, Kondo Y, Kukita I: Bystander-initiated conventional vs compression-only cardiopulmonary resuscitation and outcomes after out-of-hospital cardiac arrest due to drowning. Resuscitation 2019; 145: 166–74 MEDLINE CrossRef
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