MAINTAINING SPONTANEOUS CIRCULATION IN THE EMERGENCY DEPARTMENT (ED)

AFTER OUT-OF-HOSPITAL CARDIAC ARREST (OHCA): WHICH FACTOR IS IMPORTANT?

Eva Delsi, MD; Nanik Setijowati, MD, MKes.; Ali Haedar, MD, Sp.EM; Respati S.Dradjat, Prof., Sp.OT

Study objective: Out-of-hospital cardiac arrest (OHCA) remains a global burden in the world today. Our aim
is to describe the connection between lengths of initial cardiac arrest, initial rhythm, use of defibrillation,
airway, and drugs in the emergency department (ED) with lengths of spontaneous circulation maintained
after the return of spontaneous circulation (ROSC) in the ED.

Methods: This research is conducted for 6 months (January – June 2016) using the OHCA registry from Pan-
Asian Resuscitation Outcomes Study (PAROS). The registry is given to all ED hospitals in the Malang City area
that has already agreed in doing this research. Total of data collected during the research are 57 patients.

Results: There is a connection between lengths of cardiac arrest (p=0,048) and the use of airway adjunct
(p=0,001) with lengths of spontaneous circulation maintained in the ED after ROSC. There is no relation
between the initial rhythm (p=1,000), use of defibrillator (p=1,000), and drugs (p=0,205) in the ED with
lengths of spontaneous circulation maintained after ROSC. We also found no significant factors that is much
more important than the other when it comes to what makes an OHCA patient last longer after ROSC in the
ED.

Conclusion: There is no one specific factor that is more important than the others in connections to lengths
of spontaneous circulation maintained in the ED. The chain of survival must be fixed in every link, such as
building an integrated EMS and helping people to learn what they can do to help OHCA patients.

Keywords : emergency department, OHCA, ROSC

1
INTRODUCTION
Cardiac arrest remains a global burden in medicine today. In the US, it happens in about 360.000
people a year (Wong et al., 2014). In Asia, such as South Korea, it happens in about 39,3 per 100.000 people
(Yang et al., 2015).
The need for a registry data on an out-of-hospital cardiac arrest (OHCA) and factors that influences
survival is crucial in order to understand, identify, and analyze the things that needs to be done in a country.
A registry was formed based on the Utstein style by Pan-Asian Resuscitation Outcomes Study (PAROS) that
has been doing a research on [100] out-of-hospital cardiac arrest (OHCA) patients since 2009. Data are
collected using a questionnaire with some adjustments for the Asia-Pacific region (Ong et al., 2011).
Indonesia, with its vast population of 252 million people, does not have much data on this matter.
The lack of data collection, integrated Emergency Medical Service (EMS), and registry on OHCA patients
decreases the awareness towards its importance. The preliminary data using PAROS registry on OHCA was
conducted in Malang City, the second largest city in the East Java, with approximately 837.00 occupants. It
concludes that all OHCA patients did not receive any treatment in the [200] early seconds of cardiac arrest
(Supriadi et al., 2015).
The five chain of survival recommended by the American Heart Association (AHA) remains as a
worldwide guideline in treating OHCA patients. These chains, starting from recognizing and activating the
EMS team upon an arrest, up to post cardiac arrest care in the hospital, has to be done in a synchronized
and integrated pattern to achieve the best possible treatment (Travers et al., 2010).
There are many factors that can influence an OHCA patient to survive after returning to
spontaneous circulation. Time of initial cardiac arrest, initial cardiopulmonary resuscitation (CPR) given,
initial [300] cardiac arrest rhythm, use of a defibrillator, airway adjuncts, and drugs on resuscitation are
among those factors. Despite all of those factors, one of the many studies about OHCA claims that the initial
cardiac arrest rhythm factor is the most important factor influencing the survival of an OHCA patient
(Vancini-Campaharo et al., 2015).
This study aims to explore factors of importance for OHCA patient who survived in the emergency
department (ED) after the return of spontaneous circulation (ROSC). Those factors are lengths of initial
cardiac arrest, initial cardiac rhythm, use of defibrillator, airway adjuncts, and drugs upon resuscitation in
the [400] ED. This study also looks at whether there are any differences in the length of spontaneous
circulation maintained after achieving ROSC in an OHCA patient in the public and private hospitals. The
hypothesis was that the length of the initial cardiac arrest before receiving any treatment acts as the most
important role in increasing the chance of maintaining spontaneous circulation in the ED and that there is no
differences in either hospitals.

2
METHODS
Study Design
For over 6 months, January – June 2016, we have distributed the OHCA registry from PAROS to
every ED participants throughout Malang City. We used an analytic observational [500] research design with
a cross sectional study approach to assess the connection between lengths of initial cardiac arrest, initial
cardiac rhythm, the use of defibrillator, airway adjuncts, and drugs for resuscitation in the ED with lengths of
spontaneous circulation maintained in the public and private hospitals ED. All non-trauma OHCA patients
within the age of 18 and above were included in this study.
The data was taken by health workers (doctor or nurse) who fill in the registry after helping the
OHCA patients who came to the ED or an ambulance staff who helps at the scene or in the [600] ambulance.
Any information regarding the patient’s data are collected from the patient’s family or anyone who knew
the patient’s history. In this study, we divided the length of spontaneous circulation maintained in the ED to
less than or equal to 8 hours and more than 8 hours. This decision was based on the hospitals policy on
patients’ maximum length of stay in the ED.

Statistical Analysis
The results were analyzed using SPSS. The connection between the initial rhythm, the use of
defibrillator, airway adjuncts, and drugs in the ED with ROSC and how long the patient survived in the ED
were analyzed [700] using the chi-square test. The connection between lengths of initial arrest with ROSC
and lengths of spontaneous circulation maintained in the ED were analyzed using the Mann-Whitney test.
The influence between all five independent variables with lengths of spontaneous circulation maintained in
the ED were analyzed using the logistic regression test, with a 95% degrees of trust, α=0,05 significant if
p<0,05.

RESULT
Characteristics of Study Subjects
There were 57 patients with out-of-hospital cardiac arrest who were included in this study, where
most of them were transferred to the public hospital (75,4%). The amount of patients (24,6%) who does not
have or presumed to not [800] have any comorbidities at all, are caused by their tendency to neglect their
own disease. While the majority of OHCA patients occurred at home (77,2%), a large number underwent
more than 5 minutes of initial cardiac arrest without any initial CPR attempts before coming to the ED
(71,9%). This is due to the lack of knowledge in bystander basic life support (BLS). Most of them are being
transported using a non-ambulance vehicle (73,7%), including those who were sent to the public hospital,

3
because they do not know who or what number to contact for an ambulance (Silvalila et al., 2014). [900]
Characteristics of the study sample are included in Table 1.
Table 1. Characteristics of OHCA patients in Malang City emergency departments from January 2016 to June 2016.
All hospitals Public hospital Private hospital
n (%) n (%) n (%)
Sex:
Male 37 (64,9) 29 (67,4) 7 (50)
Female 20 (35,1) 14 (32,6) 7 (50)
Age:
Mean ± SD (years) 56 ± 15 53 ± 14 62 ± 14
Amount of comorbidities:
None 14 (24,6) 9 (20,9) 5 (35,7)
1 comorbidity 23 (40,3) 19 (44,2) 4 (28,6)
2 comorbidities 14 (24,6) 9 (20,9) 5 (35,7)
3 comorbidities 6 (10,5) 6 (14,0) 0 (0)
Means of transportation:
Ambulance 15 (26,3) 10 (23,3) 5 (35,7)
Private vehicle 22 (38,6) 14 (32,6) 8 (57,1)
Public vehicle 20 (35,1) 19 (44,2) 1 (7,1)
Location of cardiac arrest:
Home 44 (77,2) 30 (69,8) 14 (100)
In the ambulance 7 (12,3) 7 (16,3) 0
Private vehicle 6 (10,5) 6 (14) 0
ROSC
Yes 16 (28,1) 15 (34,9) 1 (7,1)
No 41 (71,9) 28 (65,1) 13 (92,9)
Length of initial cardiac
arrest:
0-5 minutes 16 (28,1) 14 (32,67) 2 (14,3)
6-10 minutes 15 (26,3) 14 (32,6) 1 (7,1)
More than 10 minutes 26 (45,6) 15 (34,9) 11 (78,6)

Main Results
From the research data in table 2, we can see that there is a significant connection between the
lengths of the initial cardiac arrest with ROSC in all hospitals (p=0,027). But it is not significant when
compared separately for public and private hospitals.

4
Table 2. Connections between lengths of initial cardiac arrest with ROSC in OHCA patients presented to the public and
private hospitals emergency department in Malang City.
ROSC
All hospitals Public hospital Private hospital
n (%) P n (%) p n (%) P
Lengths of initial cardiac arrest 0,027* 0,134* 0,233*
ROSC after initial cardiac arrest 16 (28.1) 15 (34,9) 1 (7,1)
No ROSC after initial cardiac arrest 41 (71,9) 28 (65,1) 13 (92,9)
*Mann-Whitney test

Data in table 3 shows that there is no connection between the initial rhythm (p=1,000) and the use
of defibrillator (p=1,000) with ROSC in all the hospitals. But there are a number of patients who experienced
ROSC after OHCA even without an initial shockable [1000] rhythm. The use of an adjunct airway (p=0,000)
and drugs (p=0,021) in the ED has proven to have a connection with ROSC for OHCA patients in all hospitals.
But it is not significant when it is compared with both hospitals separately, because there are only a few
patients being given that treatment in the private hospitals.
From the data in table 4, we can see that the initial cardiac rhythm, the use of defibrillator, and
drugs in the ED have no connection with lengths of spontaneous circulation maintained in the ED for OHCA
patients. But the length of the initial [1100] cardiac arrest and use of airway adjuncts in OHCA patients have
a connection with lengths of spontaneous circulation maintained in the ED. The length of spontaneous
circulation maintained in the ED could not be compared when separating the hospitals into public and
private hospital, because a majority of patients did not achieve ROSC in the private hospital.

5
Table 3. Connections between the initial cardiac rhythm, use of defibrillator, airway adjuncts, and drugs in the ED with
ROSC in OHCA patients presented to the public and private hospitals in Malang City,.
ROSC
All hospitals Public hospital Private hospital
n (%) p n (%) p n (%) P
Initial rhythm in the ED 1,000* 0,535* 0,143*
Shockable:
Yes 1 (1,7) 0 1 (7,1)
No 3 (5,3) 2 (4,7) 1 (7,1)
Unshockable:
Yes 15 (26,3) 15 (34,9) 0
No 38 (66,7) 26 (60,4) 12 (85,8)
Use of defibrillator in the ED 1,000* 0,535* 0,143*
Use defibrillator:
Yes 1 (1,7) 0 1 (7,1)
No 3 (5,3) 2 (4,7) 1 (7,1)
Did not used defibrillator:
Yes 15 (26,3) 15 (34,9) 0
No 38 (66,7) 26 (60,4) 12 (85,8)
Use of airway adjuncts in the ED 0,000* 0,000* 0,143*
Uses airway adjuncts:
Yes 16 (28) 15 (34,9) 1 (7,1)
No 5 (8,8) 4 (9,3) 1 (7,1)
No airway adjuncts:
Yes 0 0 0
No 36 (63,2) 24 (55,8) 12 (85,8)
Drugs in the ED 0,021* 1,000* 0,286*
Gives drugs:
Yes 16 (28) 15 (34,9) 1 (7,1)
No 30 (52,7) 27 (62,8) 3 (21,4)
Do not give drugs:
Yes 0 0 0
No 11 (19,3) 1 (2,3) 10 (71,5)

*Chi-square test

6
Table 4. Connections between lengths of initial cardiac arrest occurred with lengths of spontaneous circulation
maintained in the ED after ROSC in OHCA patients presented in Malang City hospitals.
Lengths of spontaneous
circulation maintained in the ED
n (%) p
Lengths of initial cardiac arrest occurred 0,048*
Less than or equal to 8 hours or 480 minutes 51 (89,5)
More than 8 hours or 480 minutes 6 (19,5)
Initial cardiac rhythm in the ED 1,000**
Shockable 4 (7,0)
Unshockable 53 (93,0)
Defibrillation in the ED 1,000**
Defibrillate 4 (7,0)
No defibrillation 53 (93,0)
Airway adjuncts in the ED 0,001**
Used 21 (36,8)
Not used 36 (63,2)
Drugs in the ED 0,205**
Used 46 (80,7)
Not used 11 (19,3)

*Mann-Whitney test.
**Chi-square test

The influence of lengths of initial cardiac arrest, initial cardiac rhythm, use of defibrillator, airway
adjuncts, and drugs in the ED with the length of spontaneous circulation maintained in the ED
Of the five independent variables, lengths of initial cardiac arrest, use of [1200] airway adjuncts,
and drugs in the ED can be calculated using the logistic regression test, while the other two variables (initial
cardiac rhythm and the use of defibrillator in the ED) could not because the requirement is if p<0,25. Using
the summary model (Nagelkerke R Square), as much as 43,9% are being influence, while the rest are
described by other variables out of the three variables. After finishing the equations, it concludes that even
though the three variables have met all the requirements, it cannot be made as an equation, because all the
variables result becomes insignificant.

DISCUSSION
This study [1300] provides information about which ED factors is the most important thing in
maintaining the length of spontaneous circulation in the ED and whether it differs between the public and
private hospitals in Malang City. The preliminary studies lacks information on whether there was any

7
relation between OHCA patients who survived in the ED after ROSC with any treatment in the ED itself
(Hadimuljono et al., 2015; Supriadi et al., 2015). This study shows us that there is not a single treatment that
is the most important thing to do in maintaining a spontaneous circulation in an OHCA patient in [1400] the
ED without also concerning the other management. It also shows that there is a significant connection
between lengths of initial cardiac arrest and the use of airway adjuncts with lengths of spontaneous
circulation maintained in the ED.
In this study, we were able to see that there is a significant connection between lengths of initial
cardiac arrest with lengths of spontaneous circulation maintained in the ED (p=0,048). If an OHCA patient is
resuscitated at an earlier time, the spontaneous circulation can be maintained much longer. Without early
treatment, especially in the first 5 minutes of cardiac arrest, the chance of surviving an OHCA event
decreases to 7-10% for each minute (American Heart Association, 2013). We also noticed that the [1500]
majority of OHCA patients (77,2%) were found in their home by their relatives (table 1). But due to the lack
of knowledge, they did not know how to perform a bystander CPR before transporting the patient to the
nearest clinic or hospital. One study noted that 81,3% of OHCA patients were located in their homes, but
they manage to survive because were given a bystander CPR (Bobrow et al., 2010).
A total of 16 (28,1%) patients achieves ROSC (table 1). The majority of patients were resuscitated in
the public hospital (also a tertiary hospital), except for one patient who achieves [1600] ROSC in the private
hospital (non-tertiary hospital). However, there were 6 patients who manage to maintain their spontaneous
circulation for more than 8 hours. All of them were treated in the public hospital. Although there was one
patient who achieves ROSC in the private hospital, but the patient only survives less than 8 hours in the ED.
This may be due to the lack of training for health workers on OHCA management. But it can also be due to
the late presentation of the patient to the ED without any management during the first few minutes of
cardiac arrest. Previous [1700] study suggested that the higher survival rate reported at tertiary centers may
be caused by referral bias with patients presenting with a worse general health status admitted more often
to non-tertiary hospitals (Søholm et al., 2015). Another study stated that admission to tertiary centers is
associated with lower mortality rates after OHCA compared with non-tertiary hospitals (Søholm et al.,
2013).
From this study also, we can see that there is a significant connection between using an airway
adjunct with lengths of spontaneous circulation maintained in the ED (p=0,001). This is similar to a previous
study stating that an OHCA patient [1800] who uses an endotracheal tube (ETT) exists longer than those who
did not (Benoit et al., 2015; Hadimuljono et al., 2015; Kang et al., 2016). But there is a difference between
using an airway adjunct with ROSC in the public hospital (p=0,000) compared to the private hospital
(p=0,143). This could be due to the lack of experience and skills of the medical team in the hospital. The 5
patients who did not achieve ROSC even after intubation (table 3) could be because they did not receive any

8
treatment in the first few minutes and it made the resuscitation in the [1900] ED not optimal. As a note, no
airway adjuncts in this study means that those patients who were not intubated, are ventilated using a bag-
valve mask and an oropharyngeal airway.
The first 5 minutes after a cardiac arrest, the heart experience an electrical phase, which resulted in
ventricle fibrillation (VF) or pulseless ventricle tachycardia (VT) on the electrocardiogram (ECG) (Weisfeldt,
2004). In this study, we found that there is no relation between the initial cardiac rhythm (p=1,000) and the
use of defibrillators (p=1,000) in the ED with ROSC and lengths of spontaneous circulation maintained in all
hospital ED. This result [2000] is contradictive to other studies saying that the initial rhythm is the most
important factor influencing the survival of an OHCA patient (Vancini-Campaharo et al., 2015). This could be
due to the fact that the majority of patients who were brought to the ED in Malang City, whether to a public
or private hospital, had a cardiac arrest for more than 5 minutes without any early treatment being given.
The chance of being found with a shockable rhythm in the ED decreases. But there are some patient (26,3%)
who managed to achieve ROSC even without a shockable rhythm in the [2100] initial presentation. This
result is contradictive to a study which stated that predictors for survival after OHCA were pulseless VT/VF
as the presenting initial cardiac rhythm (Wibrandt et al., 2015). But another study stated that half of the
patients with initial PEA who have been considered to have poor prognosis can survive (Saarinen et al.,
2012). Another one stated that in patients with an initial non-shockable rhythm after OHCA, a subsequent
conversion to shockable rhythm during resuscitation efforts was associated with increased odds for survival
and favorable neurological outcomes (Goto et al., 2014). The same result occured in this study [2200] when
those patients were converted from a non-shockable rhythm to a shockable rhythm during resuscitation in
the ED.
This study shows that there is no relation between the use of drugs during resuscitation with ROSC
of an OHCA patient in either hospitals. In fact, some of the patients were not given any drugs during the
resuscitation attempt. This is in fact contradictive to the Advanced Cardiovascular Life Support (ACLS)
guidelines recommended from AHA on managing cardiac arrest patients (Neumar et al., 2010). This could be
due to the lack of understanding about the ACLS algorithm for cardiac arrest within the [2300] medical team
itself.
This study shows that there is a connection between lengths of initial cardiac arrest, the use of an
airway adjunct and drugs in the ED with lengths of spontaneous circulation maintained after achieving ROSC
in the ED. But this data also provides information that even though there are some OHCA patients that can
survive after ROSC, when it comes to how long a patient can survive after ROSC in the ED, there are a lot of
other factors that needs to be look at other than the factors in the ED. These include the prehospital factors
and the [2400] post cardiac arrest care.

9
 Aside from the data given here, this data has its limitations. This study is only limited to a maximum
of 8 hours of management in the ED, so the effect of all treatment that has been given with lengths of
spontaneous circulation maintained in the ED could not be evaluated. Besides that, the number of hospitals
studied in this research is very limited, so it did not fully show the real condition that is happening in Malang
City. But do note that the majority of OHCA patients sent to the public hospitals were already being treated
earlier [2500] in other facilities, including private hospitals.

CONCLUSION
Among patients suffering from an out-of-hospital cardiac arrest, there is no one specific factor that
is more important than the others in connection to the length of spontaneous circulation maintained in the
ED, whether it is in a public or private hospital. The chain of survival must be fixed in every link, such as
building an integrated EMS and helping people to learn and understand what they can do to help OHCA
patients.

REFERENCES
1. Wong MKY, Morrison LJ, Qiu F, et al. Trends in short- and long-term survival among out-of-hospital
cardiac arrest patients alive at hospital arrival. Circulation. 2014;130:1883-1890.
2. Yang HJ, Kim GW, Kim H, et al. Epidemiology and outcomes in out-of-hospital cardiac arrest: A report
from the NEDIS-based cardiac arrest registry in Korea. J Korean Med Sci. 2015;30:95-103.
3. Ong MH, Sang DS, Tanaka H, et al. Pan-Asian Resuscitation Outcomes Study (PAROS): Rationale,
Methodology, and Implementation. Academic Emergency Medicine. 2011;18:890–897.
4. Ong MH, Sang DS, Tanaka H, et al. Data Supplement S1. PAROS Taxonomy, Version 1.0, 14 June
2010.
5. Supriadi A, Dradjat RS, Haedar A, et al. Faktor-faktor prarumah sakit yang mempengaruhi
kembalinya sirkulasi spontan pada pasien henti jantung di luar rumah sakit. [Thesis]. Universitas
Brawijaya, Malang. 2015.
6. Travers AH, Rea TD, Bobrow BJ, et al. Part 4: CPR Overview 2010 American Heart Association
Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation.
2010;122:S676-S684.
7. Vancini-Campanharo CS, Vancini RL, de Lira CAB, et al. Cohort study on the factors associated with
survival post-cardiac arrest. Sao Paolo Med J. 2015;133(6):495-501.
8. Silvalila M, Dradjat RS, Haedar A, et al. Faktor-faktor yang mempengaruhi pemilihan alat transportasi
medis. [Thesis]. Universitas Brawijaya, Malang. 2014.
9. Hadimuljono E, Dradjat RS, Haedar A, et al. Hubungan antara penanganan jalan napas dengan
kembalinya sirkulasi spontan pada penderita henti jantung. [Thesis]. Universitas Brawijaya, Malang.
2015.
10. American Heart Association. 2013. Fact sheet: Rural and Community Access to Emergency Devices.
Available at: www.heart.org/policyfactsheets. Accessed August 27, 2015.
11. Bobrow BJ, Spaite DW, Berg RA, et al. Chest compression-only CPR by lay rescuers and survival from
out-of-hospital cardiac arrest. JAMA. 2010; 304 (13): 1447-1454.
12. Søholm H, Kjaergaard J, Bro-Jeppesen J, et al. Prognostic implications of level-of-care at tertiary
heart centers compared with other hospitals after resuscitation from out-of-hospital cardiac arrest.
Circulation. 2015;8:268-276.

10
13. Søholm H, Wachtell K, Nielsen SL, et al. Tertiary centers have improved survival compared to other
hospitals in the Copenhagen area after out-of-hospital cardiac arrest. Resuscitation. 2013;84:162-
167.
14. Benoit JL, Gerecht RB, Steurwald MT, et al. Endotracheal intubation versus supraglottic airway
placement in out-of-hospital cardiac arrest: A meta-analysis. Resuscitation. 2015;93:20-26.
15. Kang K, Kim T, Ro YS, et al. Prehospital endotracheal intubation and survival after out-of-hospital
cardiac arrest: results from the Korean nationwide registry. Am J Emerg Med. 2016;34:128-132.
16. Weisfeldt ML, MD. A three phase temporal mode for cardiopulmonary resuscitation following
cardiac arrest. Transactions Of The American Clinical And Climatological Association. 2004;115:115-
122.
17. Wibrandt I, Norsted K, Schmidt H, et al. Predictors for outcome among cardiac arrest patients: the
importance of initial cardiac arrest rhythm versus time to return of spontaneous circulation, a
retrospective cohort study. BMC Emerg Med. 2015;15:3.
18. Saarinen S, Kamarainen A, Silfvast T, et al. Pulseless electrical activity and successful out-of-hospital
resuscitation - long term survival and quality of life: an observational cohort study. Scandinavian
Journal of Trauma, Resuscitation and Emergency Medicine. 2012;20:74.
19. Goto Y, Maeda T, and Nakatsu-Goto Y. Prognostic implications of conversion from nonshockable to
shockable rhythms in out-of-hospital cardiac arrest. Critical Care. 2014;18:528.
20. Neumar RW, Otto CW, Link MS, et al. Part 8: Adult Advanced Cardiovascular Life Support 2010
American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care. Circulation, 2010; 122: S729-S767.

11