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Study Objective: SARS-CoV-2 represents an occupational risk to paramedics, who work in uncontrolled environments. We sought to identify the occupation-specific risk to paramedics by comparing their seroprevalence of SARS-CoV-2 infection-specific antibodies to that of blood donors in Canada., Methods: In this prospective cohort study, we performed serology testing (Elecsys Anti-SARS-CoV-2 nucleocapsid assay) on samples from paramedics and blood donors (January to July 2021) in Canada. Paramedic samples were compared to blood donor samples through 1:1-matched (based on age, sex, location, date of blood collection, and vaccination status) and raking weighted comparisons. We compared the seroprevalence with a risk difference (and 95% confidence interval [CI]) and performed secondary analyses within subgroups defined by vaccination status., Results: The 1:1 match included 1,627 cases per group; in both groups, 723 (44%) were women, with a median age of 38. The raking weighted comparison included 1,713 paramedic samples and 19,515 blood donor samples, with similar characteristics. In the 1:1 match, the seroprevalence was similar (difference 1.2; 95% CI -0.20 to 2.7) between paramedics (5.2%) and blood donors (3.9%). The raking weighted comparison was consistent (difference 0.97; 95% CI -0.10 to 2.0). The unvaccinated paramedic samples, in comparison to the blood donor samples, demonstrated a higher seroprevalence in the 1:1 (difference 5.9; 95% CI 1.8 to 10) and weighted (difference 6.5; 95% CI 1.8 to 10) comparisons. Among vaccinated cases, the between-group seroprevalence was similar., Conclusion: Overall, paramedics demonstrated similar evidence of prior SARS-CoV-2 infection to that of blood donors. However, among unvaccinated individuals, evidence of prior infection was higher among paramedics compared to blood donors., (Copyright © 2022 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the individual and community health effects of task shifting for emergency care in low-resource settings and underserved populations worldwide., Methods: We systematically searched 13 databases and additional grey literature for studies published between 1984 and 2019. Eligible studies involved emergency care training for laypeople in underserved or low-resource populations, and any quantitative assessment of effects on the health of individuals or communities. We conducted duplicate assessments of study eligibility, data abstraction and quality. We synthesized findings in narrative and tabular format., Findings: Of 19 308 papers retrieved, 34 studies met the inclusion criteria from low- and middle-income countries (21 studies) and underserved populations in high-income countries (13 studies). Targeted emergency conditions included trauma, burns, cardiac arrest, opioid poisoning, malaria, paediatric communicable diseases and malnutrition. Trainees included the general public, non-health-care professionals, volunteers and close contacts of at-risk populations, all trained through in-class, peer and multimodal education and public awareness campaigns. Important clinical and policy outcomes included improvements in community capacity to manage emergencies (14 studies), patient outcomes (13 studies) and community health (seven studies). While substantial effects were observed for programmes to address paediatric malaria, trauma and opioid poisoning, most studies reported modest effect sizes and two reported null results. Most studies were of weak (24 studies) or moderate quality (nine studies)., Conclusion: First aid education and task shifting to laypeople for emergency care may reduce patient morbidity and mortality and build community capacity to manage health emergencies for a variety of emergency conditions in underserved and low-resource settings., ((c) 2021 The authors; licensee World Health Organization.)

Background: Drone-delivered defibrillators have the potential to significantly reduce response time for out-of-hospital cardiac arrest (OHCA). However, optimal policies for the dispatch of such drones are not yet known. We sought to develop dispatch rules for a network of defibrillator-carrying drones., Methods: We identified all suspected OHCAs in Peel Region, Ontario, Canada from Jan. 2015 to Dec. 2019. We developed drone dispatch rules based on the difference between a predicted ambulance response time to a calculated drone response time for each OHCA. Ambulance response times were predicted using linear regression and neural network models, while drone response times were calculated using drone specifications from recent pilot studies and the literature. We evaluated the dispatch rules based on response time performance and dispatch decisions, comparing them to two baseline policies of never dispatching and always dispatching drones., Results: A total of 3573 suspected OHCAs were included in the study with median and mean historical ambulance response times of 5.8 and 6.2 min. All machine learning-based dispatch rules significantly reduced the median response time to 3.9 min and mean response time to 4.1-4.2 min (all P < 0.001) and were non-inferior to universally dispatching drones (all P < 0.001) while reducing the number of drone flights by up to 30%. Dispatch rules with more drone flights achieved higher sensitivity but lower specificity and accuracy., Conclusion: Machine learning-based dispatch rules for drone-delivered defibrillators can achieve similar response time reductions as universal drone dispatch while substantially reducing the number of trips., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Managing out-of-hospital cardiac arrest requires paramedics to perform multiple aerosol generating medical procedures in an uncontrolled setting. This increases the risk of cross infection during the COVID-19 pandemic. Modifications to conventional protocols are required to balance paramedic safety with optimal patient care and potential stresses on the capacity of critical care resources. Despite this, little specific advice has been published to guide paramedic practice. In this commentary, we highlight challenges and controversies regarding critical decision making around initiation of resuscitation, airway management, mechanical chest compression, and termination of resuscitation. We also discuss suggested triggers for implementation and revocation of recommended protocol changes and present an accompanying paramedic-specific algorithm., Competing Interests: None of the authors has any conflict of interest to declare., (© 2020 The Author(s).)

Background: Despite high-quality cardiopulmonary resuscitation (CPR), early defibrillation, and antiarrhythmic medications, some patients remain in refractory ventricular fibrillation (VF) during out-of-hospital cardiac arrest. These patients have worse outcomes compared to patients who respond to initial treatment. Double sequential external defibrillation (DSED) and vector change (VC) defibrillation have been proposed as viable options for patients in refractory VF. However, the evidence supporting the use of novel defibrillation strategies is inconclusive. The objective of this study is to compare two novel therapeutic defibrillation strategies (DSED and VC) against standard defibrillation for patients with treatment refractory VF or pulseless ventricular tachycardia (pVT) during out-of-hospital cardiac arrest., Research Question: Among adult (≥ 18 years) patients presenting in refractory VF or pulseless ventricular tachycardia (pVT) during out-of-hospital cardiac arrest, does DSED or VC defibrillation result in greater rates of survival to hospital discharge compared to standard defibrillation?, Methods: This will be a three-arm, cluster randomized trial with repeated crossover conducted in six regions of Ontario, Canada (Peel, Halton, Toronto, Simcoe, London, and Ottawa), over 3 years. All adult (≥ 18 years) patients presenting in refractory VF (defined as patients presenting in VF/pVT and remaining in VF/pVT after three consecutive standard defibrillation attempts during out-of-hospital cardiac arrest of presumed cardiac etiology will be treated by one of three strategies: (1) continued resuscitation using standard defibrillation, (2) resuscitation involving DSED, or (3) resuscitation involving VC (change of defibrillation pads from anterior-lateral to anterior-posterior pad position) defibrillation. The primary outcome will be survival to hospital discharge. Secondary outcomes will include return of spontaneous circulation (ROSC), VF termination after the first interventional shock, VF termination inclusive of all interventional shocks, and number of defibrillation attempts to obtain ROSC. We will also perform an a priori subgroup analysis comparing rates of survival for those who receive "early DSED," or first DSED shock is shock 4-6, to those who receive "late DSED," or first DSED shock is shock 7 or later., Discussion: A well-designed randomized controlled trial employing a standardized approach to alternative defibrillation strategies early in the treatment of refractory VF is urgently required to determine if the treatments of DSED or VC defibrillation impact clinical outcomes., Trial Registration: ClinicalTrials.gov NCT04080986 . Registered on 6 September 2019.

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations for advanced life support includes updates on multiple advanced life support topics addressed with 3 different types of reviews. Topics were prioritized on the basis of both recent interest within the resuscitation community and the amount of new evidence available since any previous review. Systematic reviews addressed higher-priority topics, and included double-sequential defibrillation, intravenous versus intraosseous route for drug administration during cardiac arrest, point-of-care echocardiography for intra-arrest prognostication, cardiac arrest caused by pulmonary embolism, postresuscitation oxygenation and ventilation, prophylactic antibiotics after resuscitation, postresuscitation seizure prophylaxis and treatment, and neuroprognostication. New or updated treatment recommendations on these topics are presented. Scoping reviews were conducted for anticipatory charging and monitoring of physiological parameters during cardiopulmonary resuscitation. Topics for which systematic reviews and new Consensuses on Science With Treatment Recommendations were completed since 2015 are also summarized here. All remaining topics reviewed were addressed with evidence updates to identify any new evidence and to help determine which topics should be the highest priority for systematic reviews in the next 1 to 2 years.

The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the third annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. It addresses the most recent published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. This summary addresses the role of cardiac arrest centers and dispatcher-assisted cardiopulmonary resuscitation, the role of extracorporeal cardiopulmonary resuscitation in adults and children, vasopressors in adults, advanced airway interventions in adults and children, targeted temperature management in children after cardiac arrest, initial oxygen concentration during resuscitation of newborns, and interventions for presyncope by first aid providers. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the certainty of the evidence on the basis of the Grading of Recommendations, Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence to Decision Framework Highlights sections. The task forces also listed priority knowledge gaps for further research.

The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the second annual summary of International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations that includes the most recent cardiopulmonary resuscitation science reviewed by the International Liaison Committee on Resuscitation. This summary addresses the role of antiarrhythmic drugs in adults and children and includes the Advanced Life Support Task Force and Pediatric Task Force consensus statements, which summarize the most recent published evidence and an assessment of the quality of the evidence based on Grading of Recommendations, Assessment, Development, and Evaluation criteria. The statements include consensus treatment recommendations approved by members of the relevant task forces. Insights into the deliberations of each task force are provided in the Values and Preferences and Task Force Insights sections. Finally, the task force members have listed the top knowledge gaps for further research.

Objective: To determine if arterial oxygen and carbon dioxide abnormalities in the first 24h after return of spontaneous circulation (ROSC) are associated with increased mortality in adult out-of-hospital cardiac arrest (OHCA)., Methods: We used data from the Resuscitation Outcomes Consortium (ROC), including adult OHCA with sustained ROSC ≥1h after Emergency Department arrival and at least one arterial blood gas (ABG) measurement. Among ABGs measured during the first 24h of hospitalization, we identified the presence of hyperoxemia (PaO2≥300mmHg), hypoxemia (PaO2<60mmHg), hypercarbia (PaCO2>50mmHg) and hypocarbia (PaCO2<30mmHg). We evaluated the associations between oxygen and carbon dioxide abnormalities and hospital mortality, adjusting for confounders., Results: Among 9186 OHCA included in the analysis, hospital mortality was 67.3%. Hyperoxemia, hypoxemia, hypercarbia, and hypocarbia occurred in 26.5%, 19.0%, 51.0% and 30.6%, respectively. Initial hyperoxemia only was not associated with hospital mortality (adjusted OR 1.10; 95% CI: 0.97-1.26). However, final and any hyperoxemia (1.25; 1.11-1.41) were associated with increased hospital mortality. Initial (1.58; 1.30-1.92), final (3.06; 2.42-3.86) and any (1.76; 1.54-2.02) hypoxemia (PaO2<60mmHg) were associated with increased hospital mortality. Initial (1.89; 1.70-2.10); final (2.57; 2.18-3.04) and any (1.85; 1.67-2.05) hypercarbia (PaCO2>50mmHg) were associated with increased hospital mortality. Initial (1.13; 0.90-1.41), final (1.19; 1.04-1.37) and any (1.01; 0.91-1.12) hypocarbia (PaCO2<30mmHg) were not associated with hospital mortality., Conclusions: In the first 24h after ROSC, abnormal post-arrest oxygen and carbon dioxide tensions are associated with increased out of-hospital cardiac arrest mortality., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Measures of chest compression fraction (CCF), compression rate, compression depth and pre-shock pause have all been independently associated with improved outcomes from out-of-hospital (OHCA) cardiac arrest. However, it is unknown whether compliance with American Heart Association (AHA) guidelines incorporating all the aforementioned metrics, is associated with improved survival from OHCA., Methods: We performed a secondary analysis of prospectively collected data from the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest database. As per the 2015 American Heart Association (AHA) guidelines, guideline compliant cardiopulmonary resuscitation (CPR) was defined as CCF >0.8, chest compression rate 100-120/minute, chest compression depth 50-60mm, and pre-shock pause <10s. Multivariable logistic regression models controlling for Utstein variables were used to assess the relationship between global guideline compliance and survival to hospital discharge and neurologically intact survival with MRS ≤3. Due to potential confounding between CPR quality metrics and cases that achieved early ROSC, we performed an a priori subgroup analysis restricted to patients who obtained ROSC after ≥10min of EMS resuscitation., Results: After allowing for study exclusions, 19,568 defibrillator records were collected over a 4-year period ending in June 2015. For all reported models, the reference standard included all cases who did not meet all CPR quality benchmarks. For the primary model (CCF, rate, depth), there was no significant difference in survival for resuscitations that met all CPR quality benchmarks (guideline compliant) compared to the reference standard (OR 1.26; 95% CI: 0.80, 1.97). When the dataset was restricted to patients obtaining ROSC after ≥10min of EMS resuscitation (n=4,158), survival was significantly higher for those resuscitations that were guideline compliant (OR 2.17; 95% CI: 1.11, 4.27) compared to the reference standard. Similar findings were obtained for neurologically intact survival with MRS ≤3 (OR 3.03; 95% CI: 1.12, 8.20)., Conclusions: In this observational study, compliance with AHA guidelines for CPR quality was not associated with improved outcomes from OHCA. Conversely, when restricting the cohort to those with late ROSC, compliance with guidelines was associated with improved clinical outcomes. Strategies to improve overall guideline compliance may have a significant impact on outcomes from OHCA., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Despite increasing evidence for specialized cardiac arrest centers, the impact of transport time on out-of-hospital cardiac arrest (OHCA) patients' outcome remains unclear. We systematically reviewed the prognostic impact of transport time in OHCA patients., Methods: We searched PubMed, Embase, the Cochrane Library, and Web of Science from inception to May 2016 for studies that had reported the relationship between transport time and outcome in OHCA patients. The primary outcome was survival at hospital discharge. The secondary outcomes included neurological outcome at hospital discharge and long-term outcome., Results: From a total of 3454 titles retrieved from the literature search, 9 studies were included for final analysis. All nine studies (N=46,417) were retrospective observational studies. OHCA patients included were mostly male (61-76%), suffered a witnessed cardiac arrest in half of the cases, and had an initial shockable rhythm in one third of cases. The overall survival to hospital discharge for all cardiac rhythms was less than 6%. There was no evidence for a differential mortality risk in OHCA patients according to transport time (mean difference -0.05min [-0.86,0.76]; I 2 25%; 4 studies, 2197 patients)., Conclusion: Paramedic transport time was not associated with survival to hospital discharge or with neurological outcome at hospital discharge in adult OHCA patients. Future studies are needed to prospectively evaluate the prognostic impact of transport time particularly in rural settings and pediatric population., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Previous studies have demonstrated significant associations between cardiopulmonary resuscitation (CPR) quality metrics and survival to hospital discharge. No adequately powered study has explored the relationship between location of resuscitation (scene vs. transport) and CPR quality., Methods: We analyzed CPR quality data from treated adult OHCA occurring over a 40 month period beginning January 1, 2013 from the Rescu Epistry-cardiac arrest database. High quality CPR was defined as chest compression fraction (CCF) >0.7, compression rate >100/min and compression depth >5.0cm. Our primary objective was to compare the proportion of resuscitations for which all CPR quality benchmarks were met between scene and transport phases of resuscitation. Our secondary objectives were to compare the quality of CPR between the scene phase and transport phase of resuscitation., Results: The proportion of patients with high quality CPR was similar on scene compared to during transport (45.8% vs. 42.5%; ∆ 3.3 %; 95% CI: -1.4, 8.1). Regarding individual CPR metrics, median compression rate was higher on scene compared to transport (105.8 compressions per minute (cpm) vs. 102.0cpm; ∆ 3.8cpm; 95% CI: 2.5, 4.0), while median compression depth (5.56cm vs. 5.33cm; ∆ 0.23cm; 95% CI: 0.12, 0.26) and median CCF (0.95 vs. 0.87; ∆ 0.08; 95% CI: 0.07, 0.08) were higher during the transport phase., Conclusions: High quality CPR metrics were similar in both (scene and transport) locations of resuscitation. These results suggest that high quality, manual compressions can be performed by prehospital providers regardless of location., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Sudden cardiac arrest (SCA), confirmed absence of cardiac mechanical activity, is the leading cause of heart-related death in the US. Almost 85% of SCA occur out-of-hospital (OHCA), with very poor rates of return of spontaneous circulation (ROSC) and survival to hospital discharge. We sought to determine if diabetes status was associated with survival or ROSC following an OHCA., Methods: We completed a retrospective cohort study using data from the Toronto Regional RescuNet Epistry dataset, based upon data definitions defined by the Resuscitation Outcomes Consortium (ROC) Epistry-Cardiac Arrest and the Strategies for Post Arrest Resuscitation Care (SPARC) network datasets. Adults ≥18years of age who experienced an OHCA, had data on diabetes status, and were treated by Emergency Medical Services (EMS) between 2012-2014 were included in the analysis (n=10,097). We used bivariate analyses to examine relationships between diabetes status, Utstein elements and outcomes, and logistic regression to determine predictors of survival., Results: Diabetes prevalence was 27.8% (95% CI: 27.0-28.7). A larger proportion of those with diabetes had a non-shockable initial rhythm (28.8% vs. 25.1%; p<0.01) and did not survive to hospital discharge (92.1% vs. 89.2%, p<0.001). Diabetes status is associated with a decrease in survival, independent from a number of Utstein elements (adjusted OR=0.76; 95% CI: 0.64-0.91, p=0.003)., Conclusions: This is the first Canadian study to examine the association between diabetes status and OHCA outcomes. Our findings suggest that diabetes status prior to arrest is associated with decreased survival. The growing prevalence of diabetes globally suggests a future burden related to OHCAs., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Introduction: The Universal Termination of Resuscitation (TOR) Guideline accurately identifies potential out-of-hospital cardiac arrest (OHCA) survivors. However, implementation is inconsistent with some Emergency Medical Service (EMS) agencies using absence of return of spontaneous circulation (ROSC) as sole criterion for termination., Objective: To compare the performance of the Universal TOR Guideline with the single criterion of no prehospital ROSC. Second, to determine factors associated with survival for patients transported without a ROSC. Lastly, to compare the impact of time to ROSC as a marker of futility to the Universal TOR Guideline., Design: Retrospective, observational cohort study., Participants: Non-traumatic, adult (≥18 years) OHCA patients of presumed cardiac etiology treated by EMS providers., Setting: ROC-PRIMED and ROC-Epistry post ROC-PRIMED databases between 2007 and 2011., Outcomes: Primary outcome was survival to hospital discharge and the secondary outcome was functional survival. We used multivariable regression to evaluate factors associated with survival in patients transported without a ROSC., Results: 36,543 treated OHCAs occurred of which 9467 (26%) were transported to hospital without a ROSC. Patients transported without a ROSC who met the Universal TOR Guideline for transport had a survival of 3.0% (95% CI 2.5-3.4%) compared to 0.7% (95% CI 0.4-0.9%) in patients who met the Universal TOR Guideline for termination. The Universal TOR Guideline identified 99% of survivors requiring continued resuscitation and transportation to hospital including early identification of survivors who sustained a ROSC after extended durations of CPR., Conclusion: Using absence of ROSC as a sole predictor of futility misses potential survivors. The Universal TOR Guideline remains a strong predictor of survival., Competing Interests: The authors report no conflicts of interest. The authors alone are responsible for the writing and content of the paper., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Introduction: The role of chest compression fraction (CCF) in resuscitation of shockable out-of-hospital cardiac arrest (OHCA) is uncertain. We evaluated the relationship between CCF and clinical outcomes in a secondary analysis of the Resuscitation Outcomes Consortium PRIMED trial., Methods: We included patients presenting in a shockable rhythm who suffered OHCA prior to EMS arrival. Multivariable logistic regression was used to determine the relationship between CCF and survival to hospital discharge, return of spontaneous circulation (ROSC), and neurologically intact survival. We also performed a secondary analysis restricted to patients without ROSC in the first 10 min of EMS resuscitation., Results: Among the 2011 patients, median (IQR) age was 65 (54, 75) years, 78.2% were male, and mean (SD) CCF was 0.71 (0.14). Compared to the reference group (CCF<0.60), the odds ratio (OR) for survival was 0.49 (95% CI: 0.36, 0.68) for CCF 0.60-0.79 and 0.30 (95% CI: 0.20, 0.44) for CCF≥0.80. Results were similar for outcomes of ROSC and neurologically intact survival. Conversely, when restricted to the cohort who did not achieve ROSC during the first 10 min (n=1633), compared to the reference group (CCF<0.60), the OR for survival was 0.79 (95% CI: 0.53, 1.18) for CCF 0.60-0.79 and OR 0.88 (95% CI: 0.56, 1.36) for CCF≥0.80., Conclusions: In this study of OHCA patients presenting in a shockable rhythm, CCF was paradoxically associated with lower odds of survival. CCF is a complex measure and taken by itself may not be a consistent predictor of good clinical outcomes., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Aim: High-quality cardiopulmonary resuscitation (CPR) may improve survival. The quality of CPR performed during pediatric out-of-hospital cardiac arrest (p-OHCA) is largely unknown. The main objective of this study was to describe the quality of CPR performed during p-OHCA resuscitation attempts., Methods: Prospective observational multi-center cohort study of p-OHCA patients ≥ 1 and < 19 years of age registered in the Resuscitation Outcomes Consortium (ROC) Epistry database. The primary outcome was an a priori composite variable of compliance with American Heart Association (AHA) guidelines for both chest compression (CC) rate and CC fraction (CCF). Event compliance was defined as a case with 60% or more of its minute epochs compliant with AHA targets (rate 100-120 min(-1); depth ≥ 38 mm; and CCF ≥ 0.80). In a secondary analysis, multivariable logistic regression was used to evaluate the association between guideline compliance and return of spontaneous circulation (ROSC)., Results: Between December 2005 and December 2012, 2564 pediatric events were treated by EMS providers, 390 of which were included in the final cohort. Of these events, 22% achieved AHA compliance for both rate and CCF, 36% for rate alone, 53% for CCF alone, and 58% for depth alone. Over time, there was a significant increase in CCF (p < 0.001) and depth (p = 0.03). After controlling for potential confounders, there was no significant association between AHA guideline compliance and ROSC., Conclusions: In this multi-center study, we have established that there are opportunities for professional rescuers to improve prehospital CPR quality. Encouragingly, CCF and depth both increased significantly over time., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: Pre-shock pause duration of <20s is associated with improved survival after cardiac arrest. Manual mode defibrillation has been associated with the shortest duration of pre-shock pause but is largely practiced by advanced life support paramedics (ALS) whereas defibrillator only paramedics (basic life support or BLS) routinely use the defibrillator in automatic mode., Objective: We sought to explore the relationship between manual mode defibrillation, pre-shock pause duration and rate of inappropriate shocks when defibrillation is provided by ALS vs. BLS trained in manual mode defibrillation., Methods: We performed a retrospective review of all treated non-traumatic adult out-of-hospital cardiac arrest (OHCA) presenting in a shockable rhythm over a one year period beginning January 1, 2012. Our primary outcome measure was the proportion of manual mode shocks delivered by BLS with pre-shock pause duration of <20s when compared to ALS. Our secondary outcome measures were the duration of pre-, post- and peri-shock pause and the proportion of appropriate shocks (defined as correct identification and shock delivery to patients in a shockable rhythm) delivered by either level of paramedic. This study had a power of 90% to detect an absolute difference of 15% between paramedic levels in proportion of shocks delivered with pre-shock pause duration <20s., Results: Among 2019 treated OHCA, 335 (20%) presented in a shockable rhythm. Manual defibrillation was performed in 155 (46%) of these cases (196 shocks by ALS, 143 shocks by BLS). There were no differences in the proportion of shocks delivered with pre-shock pause duration <20s (ALS 82.8% vs. BLS 84.8%, p=.65) nor pre-shock pause duration (s) (median, Q1, Q3); ALS: 12.0 (7.0,17.0) vs. BLS: 11.0 (5.0,17.0), p=.13 while BLS had a significantly shorter peri-shock pause duration (s) (median, Q1, Q3); ALS: 17.0 (12.0, 23.0) vs. BLS: 15.0 (9.0, 22.0), p=.05. There were no differences in the rate of inappropriate shocks (ALS 1.0% vs. BLS 0.7%), p=1.0 between levels of paramedics., Conclusions: Manual mode defibrillation by BLS paramedics produced similar measures of pre-shock pause duration when compared to ALS paramedics without increasing the incidence of inappropriate shocks. Further study is required to determine the potential impact of BLS manual mode defibrillation on clinical outcomes., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: The incidence of chronic diseases, including diabetes mellitus (DM), heart failure (HF) and chronic obstructive pulmonary disease (COPD) is on the rise. The existing health care system must evolve to meet the growing needs of patients with these chronic diseases and reduce the strain on both acute care and hospital-based health care resources. Paramedics are an allied health care resource consisting of highly-trained practitioners who are comfortable working independently and in collaboration with other resources in the out-of-hospital setting. Expanding the paramedic's scope of practice to include community-based care may decrease the utilization of acute care and hospital-based health care resources by patients with chronic disease., Methods/design: This will be a pragmatic, randomized controlled trial comparing a community paramedic intervention to standard of care for patients with one of three chronic diseases. The objective of the trial is to determine whether community paramedics conducting regular home visits, including health assessments and evidence-based treatments, in partnership with primary care physicians and other community based resources, will decrease the rate of hospitalization and emergency department use for patients with DM, HF and COPD. The primary outcome measure will be the rate of hospitalization at one year. Secondary outcomes will include measures of health system utilization, overall health status, and cost-effectiveness of the intervention over the same time period. Outcome measures will be assessed using both Poisson regression and negative binomial regression analyses to assess the primary outcome., Discussion: The results of this study will be used to inform decisions around the implementation of community paramedic programs. If successful in preventing hospitalizations, it has the ability to be scaled up to other regions, both nationally and internationally. The methods described in this paper will serve as a basis for future work related to this study., Trial Registration: ClinicalTrials.gov: NCT02034045. Date: 9 January 2014.