Out-of-hospital cardiac arrest in Finland

Public examination of a doctoral dissertation in the field of Emergency Medicine

Doctoral candidate: Lic Med Pamela Hiltunen

Date and venue: 29.4.2016 at 12 noon, Kuopio University Hospital, Auditorium 2

Language of the public examination: Finnish

Language of the dissertation: English

Out-of-hospital cardiac arrest (OHCA) remains a major health challenge worldwide. Despite the development of medicine and prehospital care during the last decades, only a modest increase in survival has been reported, and overall survival has remained low. After cardiac arrest, there are only a few minutes for effective resuscitation. Optimisation of survival is ideally achieved by strengthening all links in the “chain of survival”: 1) early recognition of cardiac arrest, 2) early cardiopulmonary resuscitation, 3) early defibrillation and 4) post-resuscitation care.

The aim of this prospective cohort study was to describe the epidemiology and outcomes of OHCA and study the elements of the “chain of survival” in Finland. The study area included southern and eastern Finland. For six months, data from all cases dispatched as cardiac arrests in the Emergency Medical Dispatch Centre inside the study area were collected to a combined database. Additionally, Emergency Medical Services (EMS) personnel documented all cardiac arrests according the Utstein template, and this information was linked to the database. Moreover, data for patients successfully resuscitated prehospitally and admitted to the intensive care unit (ICU) were collected for 12 months. This information also included the use of therapeutic hypothermia (TH) and involved nearly every ICU in Finland.

This study found an incidence of EMS-attempted resuscitation of 51/100,000 inhabitants/year. The emergency medical dispatchers recognised 80.3% of cardiac arrests as the reason for the emergency call. One-third had a primary shockable rhythm, and more than half of the patients had a cardiac arrest of presumed cardiac origin. Nearly half of the patients received bystander cardiopulmonary resuscitation (CPR) before EMS arrival. Overall survival at one year was 13.4%, with 32.7% survival for patients resuscitated from shockable rhythms and 4.6% for patients resuscitated from nonshockable rhythms. A primary shockable rhythm, short delays from collapse to initiation of CPR and to EMS arrival on scene, the presence of an EMS physician during OHCA treatment and the use of TH for patients resuscitated from shockable rhythms were associated with improved survival. EMS personnel most commonly used endotracheal intubation as an airway technique. Endotracheal intubation was usually performed by an advanced life support (ALS) provider. Overall success rates of airway management for both basic level and ALS personnel were within acceptable levels. TH was widely implemented in intensive care units, and was also in use for patients with a non-shockable primary rhythm. Survival to hospital discharge among ICU-treated unconscious OHCA patients was 51.6% and was improved if TH was used for patients resuscitated from a shockable primary rhythm. TH was not associated with survival among patients with a non-shockable rhythm.

Overall survival from OHCA was similar to that reported earlier from Finland. Survival was improved, however, among patients resuscitated from bystander-witnessed cardiac arrest with a primary shockable rhythm of presumed cardiac origin. These survival rates are also commendable when compared to studies from other countries. The ability of Finnish dispatchers to recognise cardiac arrest was high. Bystander CPR should be increased. Current national recommendations concerning airway management in OHCA seem practical and lead to desirable results. TH was used widely in Finland and was also used for patients resuscitated from non-shockable primary rhythms.

The doctoral dissertation of Licentiate of Medicine Pamela Hiltunen, entitled Out-of-hospital Cardiac Arrest in Finland will be examined at the Faculty of Health Sciences. The Opponent in the public examination will be Professor Klaus Olkkola of the University of Helsinki, and the Custos will be Docent Ari Uusaro of the University of Eastern Finland.

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