Search

Objective: Reduced rates of bystander cardiopulmonary resuscitation (BCPR) in out-of-hospital cardiac arrest (OHCA) were observed during the Coronavirus Disease-2019 (COVID-19) pandemic in many regions. We investigated the impact of COVID-19 on barriers to Dispatcher-Assisted Cardiopulmonary Resuscitation (DA-CPR) in Singapore. Methods: This nationwide retrospective cohort study involved all calls to our national 995 call center for adult (≥ 18 years old) OHCA not witnessed by Emergency Medical Services. We reviewed audio recordings during the pandemic (January-June 2020) and pre-pandemic (January-June 2019) periods to compare the OHCA characteristics, and the types of “barriers” to DA-CPR — the reason why DA-CPR was not performed. Our primary outcome was the presence/absence of barriers to DA-CPR. Multivariable logistics regression was used to estimate the adjusted odds ratio (aOR) for the likelihood of barriers to DA-CPR accounting for patient and event characteristics. The effect of COVID-19 on DA-CPR rates was evaluated using interrupted time series analysis. Results: There were 1481 OHCA during the pandemic (median age 73 years, 62.7% male), and 1400 prior to the pandemic (median age 72 years, 63.6% male). Residential OHCA and witnessed OHCA increased during the pandemic (78.9% vs 75.5%, p=0.03 and 56.1% vs 39.9%, p Conclusion: COVID-19 did not affect callers’ willingness to perform DA-CPR. Distancing measures led to more residential arrests with an increase in proportion with barriers to DA-CPR, highlighting opportunities for public education and intervention.

Introduction: Time To first Compression (TTC) in out-of-hospital cardiac arrests (OHCA) is thought to be an important predictor of survival outcomes. Guidelines such as the Journal of American College of Cardiology Scientific Expert Panel recommend that extracorporeal membrane oxygenation (ECMO) should not be used on OHCA patients with TTC > 10 minutes. However, there is no literature validating this exclusion criterion on OHCA survival and neurological outcomes. This study aimed to evaluate the difference in neurological outcomes and survival to discharge of patients with CPR administered after 10 minutes, compared to within 10 minutes. Methodology: Data of OHCAs from 2012-2017 in Singapore were extracted from our national OHCA registry. We compared patients who received CPR within 10 minutes versus those who received CPR after 10 minutes. Primary outcomes were favorable cerebral performance (Glasgow-Pittsburgh Cerebral Performance Categories 1 and 2), and secondary were survival to hospital discharge or 30-day-survival. Results: There were 12,771 OHCAs analyzed, with 5,704 patients with TTC 10 minutes. Fewer patients survived to hospital discharge/30 th day with TTC > 10 minutes (aOR 0.43, 95%CI: 0.32-0.58) and survival with good neurological outcomes was lower (aOR 0.51; 95%CI: 0.41-0.62). Other significant predictors of good neurological outcomes included age (aOR 0.98, 95%CI: 0.98 - 0.99), witnessed arrest (aOR 2.39, 95%CI: 1.69-3.40), bystander AED (aOR 1.55, 95%CI: 1.12-2.26), and presence of shockable rhythm (aOR 8.76, 95%CI: 7.12-10.78). A cut-off of 17.5 minutes (aOR 0.43, 95%CI:0.28-0.65) resulted in Conclusion: Our study showed that there is a significant difference in survival and favourable neurological outcomes when TTC was >10 minutes. However, more data-driven cut-off timings/criteria should be considered instead of the arbitrary 10 minutes for eligibility of ECMO therapy.

Introduction: Telephone-assisted CPR (T-CPR) may improve bystander CPR (B-CPR) rates and survival from sudden cardiac arrest (SCA). The American Heart Association (AHA) has specified performance measures to ensure rapid provision of T-CPR instructions. Few studies have examined whether these individual T-CPR recommendations are associated with SCA outcomes. Objectives: We sought to assess whether the 2012 AHA Scientific Statement’s T-CPR evaluation metrics are associated with increased B-CPR and survival from SCA. We hypothesized that recognition of arrest and compliance with the T-CPR protocol will result in increased likelihood of B-CPR. Methods: We conducted a retrospective assessment of non-traumatic SCAs from the Singapore T-CPR Pan-Asian Resuscitation Outcomes Study. We modeled the likelihood of receipt of B-CPR and survival to hospital discharge controlling for potential confounders. Exposure variables were identified from the Scientific Statement including adherence to T-CPR algorithms, dispatcher recognition of need for CPR, barriers to CPR (yes/no), and time intervals. Results: From 7/2012-2016, the Singapore T-CPR registry contained 3,224 adjudicated SCA events. Mean age was 67±19, 62% of the patients were male, and 87% of the arrests occurred in the home; of these arrests, 75% received T-CPR and 4% survived to hospital discharge. Compliance with the T-CPR protocol algorithm was not associated with an increased likelihood of B-CPR and survival (p=ns, both). Dispatcher recognition of the need for CPR was associated with a 24.9 (12.9-47.9) increased likelihood of B-CPR p Conclusion: Rapid dispatch of EMS (

Introduction: Ethnicity, female gender, and older age are associated with lower rates of receipt of bystander cardiopulmonary resuscitation (B-CPR). Increasing telephone-assisted CPR (T-CPR), or provision of CPR instructions when individuals call 9-1-1, may improve B-CPR rates. It is unknown whether provision of T-CPR may overcome ethnic, gender and age variation seen in B-CPR. Objectives: We sought to assess whether provision of T-CPR may overcome ethnic, gender, and age variation seen in B-CPR. We hypothesized that the provision of T-CPR will improve B-CPR and reduce differences associated with ethnicity. Methods: We conducted a retrospective study of adult, non-traumatic out-of-hospital cardiac arrests (OHCA) from the Singapore registry (4/2010-12/2016). We assessed variation in B-CPR by ethnicity, female gender, and increased older age, stratified by receipt of T-CPR. We examined the differences using descriptive statistics and multivariable logistic regression accounting for confounding. Results: From 2010-2016, the Singapore registry contained 12,546 OHCA events. Excluding traumatic, EMS witnessed, and healthcare facility arrests, 7,997 events were analyzed. Of these, mean age was 66±19 and 65% were male. B-CPR was administered in 53% of the events, while T-CPR was provided in 30% of the events. In a univariate analysis, female gender was associated with variation in B-CPR if T-CPR was not provided (F: 29% vs M: 35%, p Conclusion: T-CPR modified the known B-CPR differences seen in ethnicity and increased older age, but did not modify differences seen in gender when controlling for other covariates. These findings may help inform public policy and methods to decrease variation and increase B-CPR.

Background: Dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) can increase bystander CPR rates and improve outcomes in out-of-hospital cardiac arrest (OHCA). Protocols used by dispatchers are designed to provide a quick assessment for prompt initiation of CPR. However, there are instances where non-cardiac arrest cases are falsely recognised by dispatchers to be in cardiac arrest. These patients may go on to receive chest compressions and potentially suffer from complications of unnecessary CPR, though the clinical implications of starting DA-CPR on these non-cardiac arrest cases have not been studied. Hence, the objectives of this study are to find the prevalence and clinical outcomes of DA-CPR in patients not in cardiac arrest in the Singapore population. Methods: This was a multi-center, observational study of all dispatcher-recognized cardiac arrests cases between January to December 2017 involving three tertiary hospitals in Singapore. Data was collected through audio review of dispatch calls from the national emergency ambulance service and information about patients’ clinical outcomes were prospectively collected from health records. Results: During the study period, dispatchers recognised 821 patients as having cardiac arrest. Of these, 40.0% (328/ 821) were not in cardiac arrest. 52.7% (173/ 328) of the non-cardiac arrest patients had chest compressions initiated under dispatcher assistance. No complications from chest compressions were reported. The top diagnoses of non-cardiac arrest patients found were cerebrovascular accidents (CVA), syncope and infection. A multiple logistic regression model with estimates adjusted for the presence or absence of chest compressions revealed that only final diagnoses of CVA (OR 20.68), infection (OR 17.34) and myocardial infarction (OR 32.19) were associated with in-hospital mortality. Conclusion: In this study, chest compressions initiated due to false recognition of cardiac arrest by dispatchers did not result in any reported complications and was not associated with in-hospital mortality. This provides reassurance for the continued implementation of DA-CPR.

Introduction: Bystander cardiopulmonary resuscitation (B-CPR) may increase a victim’s chance of survival from sudden cardiac arrest (SCA), but B-CPR rates are low in many communities. Few studies have examined the association of city-wide public health interventions on B-CPR. Objectives: We sought to assess whether there is variation in B-CPR by intervention and location of arrest. We hypothesized that implementation of dispatch-assisted CPR (DA-CPR), CPR/AED training, and a first responder mobile application (myResponder) would increase B-CPR by two-fold. Methods: We conducted a retrospective study of adult, non-traumatic SCAs from the Singapore registry (4/2010-12/2016). Interventions included DA-CPR (7/2012 - present), CPR/AED training (04/2014 - present), and myResponder (4/2015 - present). Using logistic regression, we modeled the likelihood of receiving B-CPR by increased number of interventions over time. We examined these effects together, in the home, and public accounting for patient-level confounding. Results: From 2010-2016, the Singapore registry contained 12,546 SCA events. Excluding pediatric, EMS witnessed, and healthcare facility arrests, 7,476 were analyzed. Of these, mean age was 66±15 and 68% were male. B-CPR was administered in 45% of the events and varied by location (home: 43% v public: 52%). With implementation of DA-CPR, likelihood of B-CPR increased (OR: 3.5 (2.9-4.2) p Conclusion: City-level public health interventions increased the likelihood of layperson B-CPR, while variation was seen in the home and public. Understanding the impact of public health interventions may shed light on strategies to increase B-CPR and inform targeted initiatives to improve survival from SCA.

Background All Singaporean males undergo medical screening prior to compulsory military service. A history of possible food allergy may require referral to a specialist Allergy clinic to ensure that special dietary needs can be taken into account during field training and deployment. Objective To study the pattern of food allergy among pre-enlistees who were referred to a specialist allergy clinic to work up suspected food allergy. Methods Retrospective study of all pre-enlistees registered in the Clinical Immunology/Allergy New Case Registry referred to the Allergy Clinic from 1 August 2015 to 31 May 2016 for suspected food allergy. Results One hundred twenty pre-enlistees reporting food allergy symptoms other than rash alone were referred to the Allergy Clinic during the study period. Of these, 77 (64.2%) had food allergy. Among those with food allergy, mean age was 19.1 ± 1.5 years. They comprised predominantly Chinese (66.2%) and Malays (20.8%). The most commonly reported foods were shellfish/crustaceans (78%), peanut (15.6%), and egg (6.5%). Self-limiting oral allergy syndrome, OAS (itchy lips and throat with/without lip angioedema) was the most common manifestation (n = 33, 42.9%) followed by anaphylaxis (n = 23, 29.9%). Majority of OAS was from shellfish/crustacean (90.6%); of which shrimp (30.3%), crab (15.2%), and lobster (3.0%) were the most common. Mild childhood asthma (69.7%), allergic rhinitis (6.3%), and eczema (6.1%) were the most common atopic conditions among individuals with shellfish/crustacean OAS. This pattern was similar for shellfish/crustacean anaphylaxis. Skin prick tests were most commonly positive for shrimp (OAS 87.1% vs. anaphylaxis 100%), crab (OAS 95.8% vs. 90.9%), and lobster (OAS 91.7% vs. 63.6%). Conclusion OAS to shellfish/crustaceans was more common than anaphylaxis among this study population of young males referred for food allergy symptoms other than rash alone.