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Objective: Exploit accelerometry data for an automatic, reliable, and prompt detection of spontaneous circulation during cardiac arrest, as this is both vital for patient survival and practically challenging., Methods: We developed a machine learning algorithm to automatically predict the circulatory state during cardiopulmonary resuscitation from 4-second-long snippets of accelerometry and electrocardiogram (ECG) data from pauses of chest compressions of real-world defibrillator records. The algorithm was trained based on 422 cases from the German Resuscitation Registry, for which ground truth labels were created by a manual annotation of physicians. It uses a kernelized Support Vector Machine classifier based on 49 features, which partially reflect the correlation between accelerometry and electrocardiogram data., Results: Evaluating 50 different test-training data splits, the proposed algorithm exhibits a balanced accuracy of 81.2%, a sensitivity of 80.6%, and a specificity of 81.8%, whereas using only ECG leads to a balanced accuracy of 76.5%, a sensitivity of 80.2%, and a specificity of 72.8%., Conclusion: The first method employing accelerometry for pulse/no-pulse decision yields a significant increase in performance compared to single ECG-signal usage., Significance: This shows that accelerometry provides relevant information for pulse/no-pulse decisions. In application, such an algorithm may be used to simplify retrospective annotation for quality management and, moreover, to support clinicians to assess circulatory state during cardiac arrest treatment.

Introduction: The global COVID-19 pandemic effects people and the health system. Some international studies reported an increasing number of out-of-hospital cardiac arrest (OHCA). Comparable studies regarding the impact of COVID-19 on incidence and outcome of OHCA are not yet available for Germany., Materials and Methods: This epidemiological study from the German Resuscitation Registry (GRR) compared a non-pandemic period (01.03.2018-28.02.2019) and a pandemic period (01.03.2020-28.02.2021) regarding the pandemic-related impact on OHCA care., Results: A total of 18,799 cases were included. The incidence of OHCA (non-pandemic 117.9 vs. pandemic period 128.0/100,000 inhabitants) and of OHCA with resuscitation attempted increased (66.0 vs. 69.1/100,000). OHCA occurred predominantly and more often at home (62.8% vs. 66.5%, p<0.001). The first ECG rhythm was less often shockable (22.2% vs. 20.3%, p = 0.03). Fewer cases of OHCA were observed (58.6% vs. 55.6% p = 0.02). Both the bystander resuscitation rate and the proportion of telephone guided CPR remained stable (38.6% vs. 39.8%, p = 0.23; and 22.3% vs. 22.5%, p = 0.77). EMS arrival times increased (08:39 min vs. 09:08 min, p<0.001). Fewer patients reached a return of spontaneous circulation (ROSC) (45.4% vs. 40.9%, p<0.001), were admitted to hospital (50.2% vs. 45.0%, p<0.001), and discharged alive (13.9% vs. 10.2%, p<0.001)., Discussion: Survival after OHCA significantly decreased while the bystander resuscitation rate remained stable. However, longer EMS arrival times and fewer cases of witnessed OHCA may have contributed to poorer survival. Any change to EMS systems in the care of OHCA should be critically evaluated as it may mean a real loss of life-regardless of the pandemic situation., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: PR works as the scientific coordinator of the German Resuscitation Registry. JW, JTG, MF, AB, SB, and SS are members of the steering committee of the German Resuscitation Registry. JTG is the spokesperson of the steering committee.

Background: Out-of-hospital cardiac arrest (OHCA) due to trauma is rare, and survival in this group is infrequent. Over the last decades, several new procedures have been implemented to increase survival, and a "Special circumstances chapter" was included in the European Resuscitation Council (ERC) guidelines in 2015. This article analysed outcomes after traumatic cardiac arrest in Germany using data from the German Resuscitation Registry (GRR) and the TraumaRegister DGU® (TR-DGU) of the German Trauma Society.  METHODS: In this study, data from patients with OHCA between 01.01.2014 and 31.12.2019 secondary to major trauma and where cardiopulmonary resuscitation (CPR) was started were eligible for inclusion. Endpoints were return of spontaneous circulation (ROSC), hospital admission with ROSC and survival to hospital discharge., Results: 1.049 patients were eligible for inclusion. ROSC was achieved in 28.7% of the patients, 240 patients (22.9%) were admitted to hospital with ROSC and 147 (14.0%) with ongoing CPR. 643 (67.8%) patients were declared dead on scene. Of all patients resuscitated after traumatic OHCA, 27.3% (259) died in hospital. The overall mortality was 95.0% and 5.0% survived to hospital discharge (47). In a multivariate logistic regression analysis; age, sex, injury severity score (ISS), head injury, found in cardiac arrest, shock on admission, blood transfusion, CPR in emergency room (ER), emergency surgery and initial electrocardiogram (ECG), were independent predictors of mortality., Conclusion: Traumatic cardiac arrest was an infrequent event with low overall survival. The mortality has remained unchanged over the last decades in Germany. Additional efforts are necessary to identify reversible cardiac arrest causes and provide targeted trauma resuscitation on scene., Trial Registration: DRKS, DRKS-ID DRKS00027944. Retrospectively registered 03/02/2022., (© 2022. The Author(s).)

Aim: To introduce and evaluate a new, open-source algorithm to detect chest compression periods automatically by the rhythmic, high amplitude signals from an accelerometer, without processing single chest compression events, and to consecutively calculate the chest compression fraction (CCF)., Methods: A consecutive sample of defibrillator records from the German Resuscitation Registry was obtained and manually annotated in consensus as ground truth. Chest compression periods were determined by different automatic approaches, including the new algorithm. The diagnostic performance of these approaches was assessed. Further, using the different approaches in conjunction with different granularities of manual annotation, several CCF versions were calculated and compared by intraclass correlation coefficient (ICC)., Results: 131 defibrillator recordings with a total duration of 5755 minutes were analysed. The new algorithm had a sensitivity of 99.39 (95% CI 99.38, 99.41)% and specificity of 99.17 (95% CI 99.15; 99.18)% to detect chest compressions at any given timepoint. The ICC compared to ground truth was 0.998 for the new algorithm and 0.999 for manual annotation, while the ICC of the proposed algorithm compared to the proprietary software was 0.978. The time required for manual annotation to calculate CCF was reduced by 70.48 (22.55, [94.35, 14.45])%., Conclusion: The proposed algorithm reliably detects chest compressions in defibrillator recordings. It can markedly reduce the workload for manual annotation, which may facilitate uniform reporting of measured quality of cardiopulmonary resuscitation. The algorithm is made freely available and may be used in big data analysis and machine learning approaches., Competing Interests: Conflicts of Interest JTG has received speakers honorary from ZOLL Medical, not related to the content of this study. All other authors have no conflict of interest to declare., (Copyright © 2021 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: Witnessing an out-of-hospital cardiac arrest (OHCA) is a traumatic experience. This study analyses bystanders` psychological processing of OHCA. We examined the potential impact of bystanders performing resuscitation and the influence of the relationship between bystander and patient (stranger vs. family/friend of the patient) on the psychological processing., Methods: A telephone interview survey with bystanders, who witnessed an OHCA of an adult patient was performed weeks after the event between December 2014 and April 2016. The semi-standardized questionnaire contained a question regarding the paramount emotion at the time of the interview. In a post-hoc analysis statements given in response were rated by independent researchers into the categories "signs of pathological psychological processing", "physiological psychological processing" and "no signs of psychological distress due to the OHCA"., Results: In this analysis 89 telephone interviews were included. In 27 cases (30.3%) signs of pathological psychological processing could be detected. Bystanders performing resuscitation had a higher rate of "no signs of psychological distress after witnessing OHCA" compared to those not resuscitating (54.7% vs. 26.7%, p < 0.05; relative risk 2.01; 95%CI 1.08, 3.89). No statistical significant differences in the psychological processing could be shown for gender, age, relationship to the patient, current employment in the health sector, location of cardiac arrest or number of additional bystanders., Conclusions: One out of three bystanders of OHCA suffers signs of pathological psychological processing. This was independent of bystander´s age, gender and relationship to the patient. Performing resuscitation seems to help coping with witnessing OHCA., (© 2021. The Author(s).)

Background: Current guidelines underline the importance of high-quality chest compression during cardiopulmonary resuscitation (CPR), to improve outcomes. Contrary to this many studies show that chest compression is often carried out poorly in clinical practice, and long interruptions in compression are observed. This prospective cohort study aimed to analyse whether chest compression quality changes when a real-time feedback system is used to provide simultaneous audiovisual feedback on chest compression quality. For this purpose, pauses in compression, compression frequency and compression depth were compared., Methods: The study included 292 out-of-hospital cardiac arrests in three consecutive study groups: first group, conventional resuscitation (no-sensor CPR); second group, using a feedback sensor to collect compression depth data without real-time feedback (sensor-only CPR); and third group, with real-time feedback on compression quality (sensor-feedback CPR). Pauses and frequency were analysed using compression artefacts on electrocardiography, and compression depth was measured using the feedback sensor. With this data, various parameters were determined in order to be able to compare the chest compression quality between the three consecutive groups., Results: The compression fraction increased with sensor-only CPR (group 2) in comparison with no-sensor CPR (group 1) (80.1% vs. 87.49%; P < 0.001), but there were no further differences belonging compression fraction after activation of sensor-feedback CPR (group 3) (P = 1.00). Compression frequency declined over the three study groups, reaching the guideline recommendations (127.81 comp/min vs. 122.96 comp/min, P = 0.02 vs. 119.15 comp/min, P = 0.008) after activation of sensor-feedback CPR (group 3). Mean compression depth only changed minimally with sensor-feedback (52.49 mm vs. 54.66 mm; P = 0.16), but the fraction of compressions with sufficient depth (at least 5 cm) and compressions within the recommended 5-6 cm increased significantly with sensor-feedback CPR (56.90% vs. 71.03%; P = 0.003 and 28.74% vs. 43.97%; P < 0.001)., Conclusions: The real-time feedback system improved chest compression quality regarding pauses in compression and compression frequency and facilitated compliance with the guideline recommendations. Compression depth did not change significantly after activation of the real-time feedback. Even the sole use of a CPR-feedback-sensor ("sensor-only CPR") improved performance regarding pauses in compression and compression frequency, a phenomenon known as the 'Hawthorne effect'. Based on this data real-time feedback systems can be expected to raise the quality level in some parts of chest compression quality., Trial Registration: International Clinical Trials Registry Platform of the World Health Organisation and German Register of Clinical Trials (DRKS00009903), Registered 09 February 2016 (retrospectively registered)., Competing Interests: We have read the journal's policy and the authors of this manuscript state the following competing interests: F.L. received travel grants for scientific congresses from GS Elektromedizinische Geräte G. Stemple GmbH, Kaufering, Germany. M.H. is employed at GS Elektromedizinische Geräte G. Stemple GmbH, Kaufering, Germany. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Background: Cardiac arrest is an event with a limited prognosis which has not substantially changed since the first description of cardiopulmonary resuscitation (CPR) in 1960. A promising new treatment approach may be mechanical CPR devices (mechanical CPR)., Methods: In a retrospective analysis of the German Resuscitation Registry between 2007-2014, we examined the outcome after using mechanical CPR on return of spontaneous circulation (ROSC) in adults with out-of-hospital cardiac arrest (OHCA). We compared mechanical CPR to manual CPR. According to preclinical risk factors, we calculated the predicted ROSC-after-cardiac-arrest (RACA) score for each group and compared it to the rate of ROSC observed. Using multivariate analysis, we adjusted the influence of the devices' application on ROSC for epidemiological factors and therapeutic measures., Results: We included 19,609 patients in the study. ROSC was achieved in 51.5% of the mechanical CPR group (95%-CI 48.2-54.8%, ROSC expected 42.5%) and in 41.2% in the manual CPR group (95%-CI 40.4-41.9%, ROSC expected 39.2%). After multivariate adjustment, mechanical CPR was found to be an independent predictor of ROSC (OR 1.77; 95%-CI 1.48-2.12). Duration of CPR is a key determinant for achieving ROSC., Conclusions: Mechanical CPR was associated with an increased rate of ROSC and when adjusted for risk factors appeared advantageous over manual CPR. Mechanical CPR devices may increase survival and should be considered in particular circumstances according to a physicians' decision, especially during prolonged resuscitation., Competing Interests: The authors have declared that no competing interests exist.

Background: Out of hospital cardiac arrest (OHCA) is one of the more common causes of death in Germany. Ambulance response time is an important planning parameter for emergency medical services (EMS) systems. We studied the effect of ambulance response time on survival after resuscitation from OHCA., Methods: We analyzed data from the German Resuscitation Registry for the years 2010-2016. First, we used a multivariate logistic regression analysis to determine the effect of ambulance response time (defined as the interval from the alarm to the arrival of the first rescue vehicle) on the hospital-discharge rate (in percent), depending on various factors, including resuscitation by bystanders. Second, we compared faster and slower EMS systems (defined as those arriving on the scene within 8 minutes in more than 75% of cases or in ≤ 75% of cases) with respect to the frequency of resuscitation and the number of surviving patients., Results: Our analysis of data from a total of 10 853 patients in the logistical regression model revealed that the rate of hospital discharge was significantly affected by the ambulance response time, bystander resuscitation, past medical history, age, witnessed vs. unwitnessed collapse, the initial heart rhythm, and the site of the collapse. The success of resuscitation was inversely related to the ambulance response time; thus, among patients who did not receive bystander resuscitation, the discharge rate declined from 12.9% at a mean response time of 1 minute and 10 seconds to 6.4% at a mean response time of 9 minutes and 47 seconds. Twelve faster EMS systems and 13 slower ones were identified, with a total of 9669 and 7865 resuscitated patients, respectively. The faster EMS systems initiated resuscitation more frequently and also had a higher discharge rate with good neurological outcome in proportion to the population of the catchment area (7.7 versus 5.6 persons per 100 000 population per year, odds ratio [OR] 0.72, 95% confidence interval [0.66; 0.79], p<0.001)., Conclusion: Rapid ambulance response is associated with a higher rate of survival from OHCA with good neurological outcome. The response time, independently of whether bystander resuscitation measures are provided, ha^ a significant independent effect on the survival rate. In drawing conclusions from these findings, one should bear in mind that this was a retrospective registry study, with the corresponding limitations.

Aim: Guidelines recommend detecting return of spontaneous circulation (ROSC) by a rising concentration of carbon dioxide in the exhalation air. As CO 2 is influenced by numerous factors, no absolute cut-off values of CO 2 to detect ROSC are agreed on so far. As trends in CO 2 might be less affected by influencing factors, we investigated an approach which is based on detecting CO 2 -trends in real-time., Methods: We conducted a retrospective case-control study on 169 CO 2 time series from out of hospital cardiac arrests resuscitated by Muenster City Ambulance-Service, Germany. A recently developed statistical method for real-time trend-detection (SCARM) was applied to each time series. For each series, the percentage of time points with detected positive and negative trends was determined., Results: ROSC time series had larger percentages of positive trends than No-ROSC time series (p=0.003). The median percentage of positive trends was 15% in the ROSC time series (IQR: 5% to 23%) and 7% in the No-ROSC time series (IQR: 3% to 14%). A receiver operating characteristic (ROC) analysis yielded an optimal threshold of 13% to differentiate between ROSC and No-ROSC cases with a specificity of 58.4% and sensitivity of 73.9%; the area under the curve was 63.5%., Conclusion: Patients with ROSC differed from patients without ROSC as to the percentage of detected CO 2 trends, indicating the potential of our real-time trend-detection approach. Since the study was designed as a proof of principle and its calculated specificity and sensitivity are low, more research is required to implement CO 2 -trend-detection into clinical use., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Airway management during resuscitation attempts is pivotal for treating hypoxia, and endotracheal intubation is the standard procedure. This German Resuscitation Registry analysis investigates the influence of airway management on primary outcomes after out-of-hospital cardiac arrest, in a physician-based emergency system., Methods: A total of 8512 patients recorded in the German Resuscitation Registry (2007-2011) were analyzed. The Return of Spontaneous Circulation After Cardiac Arrest (RACA) score was used to compare observed return of spontaneous circulation (ROSC) rates with the ROSC predicted by the score and to analyze factors influencing the primary outcome. Patients were classified into three groups: difficult intubation, impossible intubation, and a control group with normal airways., Results: The observed ROSC matched the predicted ROSC in the group with difficult airways. The impossible intubation group had lower ROSC rates (31.3% vs. 40.5%; P < 0.05). Impossible intubation was more frequent in men (OR 2.28; 95% CI, 1.43-3.63; P = 0.001), young patients (OR 2.18; 95% CI, 1.26-3.76; P = 0.005) and those with trauma (OR 2.22; 95% CI, 1.01-4.85; P = 0.046). Fewer impossible intubations were reported when the emergency physicians were anesthesiologists (OR 0.65; 95% CI, 0.44-0.96; P = 0.028). If a supraglottic airway device was not used in the impossible intubation group, the observed ROSC (18.0%; 95% CI, 7.4-28.6%) was poorer than predicted (38.2%) (P < 0.05)., Conclusions: Outcomes after resuscitation attempts are poorer when endotracheal intubation is not possible. Predictive factors for impossible intubation are male gender, younger age, and trauma. Supraglottic airway devices should be used at an early stage whenever these negative factors are present.

Purpose of Review: Quick initiation of basic life support (BLS) by laypersons is one of the most successful strategies in the fight against sudden cardiac death. In developed countries, cardiac arrest is still a major contributor to avoidable death, and despite the fact that more than 50% of all cardiac arrests are witnessed, layperson BLS is performed in less than 20%. To improve this situation, BLS training in schools has been established., Recent Findings: Cardiopulmonary resuscitation (CPR) instruction including the use of automatic external defibrillators (AEDs) has shown to be feasible even for young schoolchildren, and there is an indication that respective programmes are effective to enhance patient outcome on a population basis. Earlier training may even lead to more sustainable results; however, it is reasonable to implement adjusted curricula for different child ages. The programme 'Kids Save Lives' recently endorsed by the WHO will help promoting school-based BLS training worldwide demanding education on CPR for all pupils starting at least at age 12., Summary: Resuscitation training in schools can help to increase the amount of BLS-trained population. Social skills of pupils can be improved and training can be successfully implemented independently of the pupils' age and physique.

Aim: Survival rates after out-of-hospital-cardiac-arrest (OHCA) differ widely between EMS systems. Since hypertonic saline appears to improve long-term outcome after OHCA, some local EMS systems have included it in their treatment protocols for OHCA. Our first aim was to give a quality review of one of these protocols. Our second aim was to assess whether short-term survival improves when hypertonic saline is used in resuscitation after OHCA., Methods: Matched pairs were identified for the independent "return of spontaneous circulation (ROSC) after cardiac arrest" (RACA) score variables and for use of ACD-CPR, adrenaline, and amiodarone from the German Resuscitation Registry (GRR) for January 2000 to March 2011. Patients received either 2mlkg(-1) hypertonic saline with hydroxyethyl starch (7.2% NaCl with 6% hydroxyethyl starch 200,000/0.5, HyperHAES® [HHS]) infused intravenously within 10min during CPR according to local treatment protocols or standard of care CPR (NON-HHS). The primary endpoint was admission to hospital rate (with spontaneous circulation); secondary endpoint was ROSC rate in relation to RACA score., Results: 322 matched pairs were defined for 14 variables. Predicted ROSC-rate using RACA-score was similar in HHS (44.63%) and NON-HHS (43.63%; p=0.440). In contrast, 190 (59.0%) HHS patients achieved ROSC compared with only 136 NON-HHS patients (42.2%; χ(2): p<0.0001). Short term survival measured as rate of "admission to hospital with spontaneous circulation" was achieved in 169 HHS patients (52.5%) versus 108 NON-HHS patients (33.5%) (OR 2.19; 95%CI: 1.592-3.009; χ(2): p<0.0001)., Conclusion: Locally implemented treatment protocols using hypertonic saline/HES after OHCA are safe and effective. Also, we verified that short-term survival rates were better in patients receiving HHS., (Copyright © 2014 The Authors. Published by Elsevier Ireland Ltd.. All rights reserved.)

Background: The 2010 Resuscitation Guidelines require high-quality chest compression and rapid defibrillation for patients with ventricular fibrillation with rhythm analysis and defibrillation repeated every 2 min. A lack of adherence to the guidelines by medical students was observed during simulated resuscitation training., Objectives: To assess whether real-time cardiopulmonary resuscitation guidance, including an audiovisual countdown timer, a metronome, a display of the chest compression quality and voice prompts, might improve adherence to the guidelines by medical students., Design: Randomised cross-over simulation study., Setting: Studienhospital Münster, Faculty of Medicine University Münster, Germany, Participants: One hundred and forty-one medical students (fifth year) in 47 teams., Intervention: Simulated resuscitation with and without real-time cardiopulmonary resuscitation guidance., Main Outcome Measures: The preshock pause, postshock pause, fraction of time without chest compression and defibrillation intervals. Observed quality parameters were chest compression depth and chest compression rate., Results: With real-time cardiopulmonary resuscitation guidance, there were improved mean (SD) chest compression rates (105 ± 8 vs. 121 ± 12 bpm; P < 0.005), fewer inappropriate shock intervals [median (interquartile range) 0 (1 to 5) vs. 4 (1 to 7); P < 0.005], a smaller fraction of time without chest compression (18.9 ± 4.4 vs. 22.5 ± 7.0%; P < 0.005) and shorter postshock pauses (2.3 ± 0.9 vs. 3.4 ± 1.2 s; P < 0.005)., Conclusion: Real-time cardiopulmonary resuscitation guidance significantly increased adherence to the guidelines by medical students treating simulated out-of-hospital cardiac arrest. Using a simple tool such as a countdown timer makes it possible to reduce the number of inappropriate shock intervals and time without chest compression.

Aims: Chest compression quality is a determinant of survival from out-of-hospital cardiac arrest (OHCA). ERC 2005 guidelines recommend the use of technical devices to support rescuers giving compressions. This prospective randomized study reviewed influence of different feedback configurations on survival and compression quality., Materials and Methods: 312 patients suffering an OHCA were randomly allocated to two different feedback configurations. In the limited feedback group a metronome and visual feedback was used. In the extended feedback group voice prompts were added. A training program was completed prior to implementation, performance debriefing was conducted throughout the study., Results: Survival did not differ between the extended and limited feedback groups (47.8% vs 43.9%, p = 0.49). Average compression depth (mean ± SD: 4.74 ± 0.86 cm vs 4.84 ± 0.93 cm, p = 0.31) was similar in both groups. There were no differences in compression rate (103 ± 7 vs 102 ± 5 min(-1), p=0.74) or hands-off fraction (16.16% ± 0.07 to 17.04% ± 0.07, p = 0.38). Bystander CPR, public arrest location, presenting rhythm and chest compression depth were predictors of short term survival (ROSC to ED)., Conclusions: Even limited CPR-feedback combined with training and ongoing debriefing leads to high chest compression quality. Bystander CPR, location, rhythm and chest compression depth are determinants of survival from out of hospital cardiac arrest. Addition of voice prompts does neither modify CPR quality nor outcome in OHCA. CC depth significantly influences survival and therefore more focus should be put on correct delivery. Further studies are needed to examine the best configuration of feedback to improve CPR quality and survival., Registration: ClinicalTrials.gov (NCT00449969), http://www.clinicalTrials.gov., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Introduction: Mild therapeutic hypothermia (MTH) has been shown to result in better neurological outcome after cardiopulmonary resuscitation. Percutaneous coronary intervention (PCI) may also be beneficial in patients after out-of-hospital cardiac arrest (OHCA)., Methods: A selected cohort study of 2,973 prospectively documented adult OHCA patients within the German Resuscitation Registry between 2004 and 2010. Data were analyzed by backwards stepwise binary logistic regression to identify the impact of MTH and PCI on both 24-hour survival and neurological outcome that was based on cerebral performance category (CPC) at hospital discharge. Odds ratios (95% confidence intervals) were calculated adjusted for the following confounding factors: age, location of cardiac arrest, presumed etiology, bystander cardiopulmonary resuscitation, witnessing, first electrocardiogram rhythm, and thrombolysis., Results: The Preclinical care dataset included 2,973 OHCA patients with 44% initial return of spontaneous circulation (n = 1,302) and 35% hospital admissions (n = 1,040). Seven hundred and eleven out of these 1,040 OHCA patients (68%) were also registered within the Postresuscitation care dataset. Checking for completeness of datasets required the exclusion of 127 Postresuscitation care cases, leaving 584 patients with complete data for final analysis. In patients without PCI (n = 430), MTH was associated with increased 24-hour survival (8.24 (4.24 to 16.0), P < 0.001) and the proportion of patients with CPC 1 or CPC 2 at hospital discharge (2.13 (1.17 to 3.90), P < 0.05) as an independent factor. In normothermic patients (n = 405), PCI was independently associated with increased 24-hour survival (4.46 (2.26 to 8.81), P < 0.001) and CPC 1 or CPC 2 (10.81 (5.86 to 19.93), P < 0.001). Additional analysis of all patients (n = 584) revealed that 24-hour survival was increased by MTH (7.50 (4.12 to 13.65), P < 0.001) and PCI (3.88 (2.11 to 7.13), P < 0.001), while the proportion of patients with CPC 1 or CPC 2 was significantly increased by PCI (5.66 (3.54 to 9.03), P < 0.001) but not by MTH (1.27 (0.79 to 2.03), P = 0.33), although an unadjusted Fisher exact test suggested a significant effect of MTH (unadjusted odds ratio 1.83 (1.23 to 2.74), P < 0.05)., Conclusions: PCI may be an independent predictor for good neurological outcome (CPC 1 or CPC 2) at hospital discharge. MTH was associated with better neurological outcome, although subsequent logistic regression analysis did not show statistical significance for MTH as an independent predictor for good neurological outcome. Thus, postresuscitation care on the basis of standardized protocols including coronary intervention and hypothermia may be beneficial after successful resuscitation. One of the main limitations may be a selection bias for patients subjected to PCI and MTH.

Introduction: Sudden cardiac arrest is one of the most frequent causes of death in the world. In highly qualified emergency medical service (EMS) systems, including well trained emergency physicians, spontaneous circulation may be restored in up to 53% of patients at least until admission to hospital. Compared with these highly qualified EMS systems, in other systems markedly lower success rates are observed. These data clearly show that there are considerable differences between EMS systems concerning treatment success following cardiac arrest and resuscitation, although in all systems international guidelines for resuscitation are used. This study investigates the impact of response time reliability (RTR) on cardio pulmonary resuscitation (CPR) incidence and resuscitation success using return of spontaneous circulation (ROSC) after cardiac arrest (RACA) score and data from seven German EMS systems participating in the German Resuscitation Registry., Methods: Anonymized patient data after out of hospital cardiac arrest from 2006 to 2009 of seven EMS systems in Germany were analysed to socioeconomic factors (population, area, EMS unit hours), process quality (response time reliability, CPR incidence, special CPR measures, prehospital cooling), patient factors (age, gender, cause of cardiac arrest, bystander CPR). Endpoints were defined as ROSC, admission to hospital, 24 hour survival and hospital discharge rate. For statistical analyses, chi-square, odds-ratio and Bonferroni correction were used., Results: 2,330 prehospital CPR from seven centres were included in this analysis. Incidence of sudden cardiac arrest differs from 36.0 to 65.1/100,000 inhabitants/year. We identified two EMS systems (RTR < 70%) reaching the patients within eight minutes in 62.0% and 65.6% while the other five EMS systems (RTR > 70%) achieved 70.4 up to 95.5%. EMS systems arriving relatively later at the patients side (RTR < 70%) less frequently initiate CPR and admit fewer patients alive to hospital (calculated per 100,000 inhabitants/year) (CPR incidence (1/100,000 inhabitants/year) RTR > 70% = 57.2 vs RTR < 70% = 36.1, OR = 1.586 (99% CI = 1.383 to 1.819); P < 0.01) (admitted to hospital with ROSC (1/100,000 inhabitants/year) RTR > 70% = 24.4 vs RTR < 70% = 15.6, OR = 1.57 (99% CI = 1.274 to 1.935); P < 0.01). Using ROSC rate and the multivariate RACA score to predict outcome, the two groups did not differ, but ROSC rates were higher than predicted in both groups (ROSC RTR > 70% = 46.6% vs RTR < 70% = 47.3%, OR = 0.971 (95% CI = 0.787 to 1.196); P = n.s.) (ROSC RACA RTR > 70% = 42.4% vs RTR < 70% = 39.5%, OR = 1.127 (95% CI = 0.911 to 1.395); P = n.s.)., Conclusion: This study demonstrates that on the level of EMS systems, faster ones will more often initiate CPR and will increase number of patients admitted to hospital alive. Furthermore it is shown that with very different approaches, all adhering to and intensely training in the ERC guidelines 2005, superior and, according to international comparison, excellent success rates following resuscitation may be achieved.