In the Midst of Life

rhythm abnormality, then only six per cent were discharged alive. In this audit, factors associated with an improved chance of survival included an easily treatable cardiac arrhythmia as the cause of the arrest, a prompt return of the circulation in response to cardio-pulmonary resuscitation, and the age of the patient, with those under seventy being more likely to survive. The Resuscitation Council (UK) and The Intensive Care National Audit & Research Centre (ICNARC) are collaborating to develop a national database regarding cardio-pulmonary arrests that take place in hospital† to enable analysis of the frequency of, and outcome from, resuscitationin the United Kingdom. This should result in more consistent reporting and a better understanding of what might result in improved success rates.
    The statistical likelihood of success in cardio-pulmonary resuscitation is not reflected in popular television dramas! A study of ninety-seven episodes of television medical dramas in the United States of America in 1994-1995 analysed sixty occurrences of cardio-pulmonary arrest; sixty-five per cent of these arrests occurred in children, teenagers, or young adults and sixty-seven per cent appear to have survived to hospital discharge. * Such rates are significantly higher than even the most optimistic survival rates in the medical literature and the portrayal of cardio-pulmonary resuscitation on television may lead the viewing public to have an unrealistic impression of the procedure, and its chances of success.
    Results of resuscitation for out-of-hospital arrest
    In 2004 the Ontario Pre-hospital Advanced Life Support Study of 5,638 patients who had had an out-of-hospital cardiac arrest reported that only five per cent survived to discharge from hospital.f There did not seem to be any trend towards improved survival over time with the introduction of community-based initiatives. The registry of cardiac arrests in the community of Goteborg in Sweden reported that of 5,505 patients who had suffered an out-of-hospital cardiac arrest between 1980 and 2000, between eight and nine per cent of these survived to hospital discharge. † Again there was no trend towards improvement insurvival rates over the time period of the study. A systematic review and meta-analysis published in 2010 detailing seventy-nine studies of out-of-hospital cardiac arrests involving 142,740 patients reported that twenty-four per cent reached hospital alive, but the rate of survival to hospital discharge was 7.6 per cent overall and this survival rate has remained unchanged over the last thirty years. * Again survival ratio depended on many of the same factors as in-hospital cases i.e. the speed of response, whether the patient received cardio-pulmonary resuscitation from a bystander, if the cardiac rhythm abnormality was easily treatable, or if there was an early return of spontaneous circulation.
    In 2004, a study of nearly 1,000 communities in twenty-four North American Regions reported that survival to hospital discharge was twenty-three per cent in those areas equipped with staff trained in using Automated External Defibrillators (AEDs), whereas survival was fourteen per cent in those areas without. † Increasingly, cardiac arrests which occur out-of-hospital are also being automatically treated by a special type of implanted pacemaker known as an Internal Cardiac Defibrillator (ICD). These have been available for more than ten years, and have been implanted in those people at the highest risk of developing lethal cardiac rhythm disorders. When implanted, the devices promptly diagnose and treat almost all lethal cardiac rhythm disorders within a few seconds, using an internal electric defibrillator shock. The widespread use of these devices might paradoxically skew the statistics regarding survival rates, as those not fitted with the device are likely to have less easily treatable conditions and are therefore less likely to be successfully resuscitated following a cardiac arrest.
    In2006 the Termination of Resuscitation Study investigators in Ontario reported on the development of a theoretical rule which would predict a low chance of survival from out-of-hospital cardiac arrest to hospital discharge. * Where there was no return of spontaneous circulation, no defibrillation shocks had been administered, and the arrest was not witnessed by the emergency services, the rule recommended termination of resuscitation. Of 776 patients with cardiac arrest for