when experiencing recurrent or refractory v fib.
In addition, the introduction of measuring high-performance CPR and the LUCAS mechanical
CPR device led to field reports of cardiac arrest
cases in which patients were breathing, blinking
After meeting with both cardiology groups, we
agreed to move forward with a simple protocol
of prehospital cardiac catheterization laboratory
activation for any adult with witnessed, shockable
cardiac arrest regardless of whether or not return
of spontaneous circulation (ROSC) occurred. At
the request of physician stakeholders, the interventional cardiologist involved in a case retain the
ability to determine the most appropriate course of
treatment upon arrival at the catheterization lab.
Split between the two cardiology groups, this
would amount to about one prehospital cardiac
catheterization laboratory activation per group per
month for witnessed cardiac arrest cases.
LFR paramedics now activate the cardiac catheterization lab in the same manner as they activate
it for a STEMI patient. The results have been dramatic. (See Figure 1, p. 24, and Table 1.)
On Feb. 1, 2015, the Lincoln EMS System initiated prehospital cardiac catheterization laboratory activation for any adult suffering from a
witnessed, shockable cardiac arrest.
The Utstein survival for the 16-month period
that preceded this protocol change (Oct. 1, 2013–
January 31, 2015) was 23.8% ( 5 survivors out of
21 patients). Of the 5 survivors, 4 had a cerebral
performance category (CPC) score of 1 or 2, indicating a good neurological outcome.
The Utstein survival for the 29-month period
after the protocol change (Feb. 1, 2015–June 30,
2017) is 59.2% ( 29 survivors out of 49 patients). Of
the 29 survivors, 28 had a CPC score of 1 or 2. Chi-square testing shows the increase in Utstein survival to be statistically significant, with p < 0.05.
The overall cardiac arrest survival including
all presenting cardiac rhythms during the 16
months before protocol change was 12.6%. Our
overall cardiac arrest survival in the 29 months
since the protocol change is 15.7% (50 survivors
out of 318 patients).
During the 16 months before the protocol
change was instituted, there were 21 patients
who suffered a witnessed, shockable cardiac arrest.
Of those 21 patients, 15 experienced sustained
ROSC, defined as the restoration of a palpable
pulse or a measurable blood pressure for at least
20 consecutive minutes or at the end of EMS care,
prior to hospital arrival.
intervention and the use of therapeutic hypother-
mia in the appropriate patient population.
Representatives of LFR met with Nebraska
Heart and Bryan Heart, the two cardiology groups
serving Lincoln, Neb. Both groups post excellent
door-to-balloon times for patients suffering from
ST-elevation myocardial infarctions (STEMI).
We all agreed that witnessed v fib/v tach cardiac
arrest is a survivable disease and that variability
and inconsistency in care does lead to suboptimal outcomes.
We discussed further survival prognostication
criteria that would limit cardiac catheterization
laboratory activation, such as restrictions on
age, co-morbidity factors, presence or absence of
bystander CPR, ROSC and signs of life with chest
As we reviewed cardiac arrest cases from 2014,
we determined that Lincoln averaged less than two
witnessed v fib/v tach cardiac arrests each month.
Further analysis identified cases in which patients
survived prolonged cardiac arrest resuscitations
EMS crews transport a patient from the ambulance
into the Nebraska Heart Hospital catheterization lab.
Table 1: Cardiac arrest survival
in Lincoln, Neb., 2014–2016
2014 2015 2016
(n = 4/17)
(n = 10/22)
(n = 13/18)
(n = 13/110)
(n = 21/134)
(n = 20/126)