Case

A 22-year-old pitcher gets struck in the chest by a baseball coming off the bat while at spring training camp. He goes down on the mound and is suspected to have commotio cordis.¹ The athletic trainers immediately start CPR for the witnessed cardiac arrest. Paramedics quickly arrive and wonder if they should stay on the scene or transport the patient with resuscitation still in progress.

Clinical Question

What is the best in out-of-hospital cardiac arrest (OHCA)? Remain and gain or load and go?

Background

It is unclear from the published medical literature which practice is superior in adult patients with refractory OHCAs. Some countries have a physician-led model, like in Europe, and provide more care in the field. In contrast, the North American model has traditionally been “load and go.”

In the U.S., there is a fair bit of variability. Some emergency medical service (EMS) agencies transport almost all patients regardless of return of spontaneous circulation (ROSC), while others rarely transport if ROSC is not achieved. Which approach provides the best patient-oriented outcome has not been determined.

Reference: Grunau, et al. Association of intra-arrest transport vs continued on-scene resuscitation with survival to hospital discharge among patients with out-of-hospital cardiac arrest. JAMA. 2020;324(11):1058–1067.

• Population: Adults 18 years and older with non-traumatic OHCA (defined as persons found apneic and without a pulse who underwent either external defibrillation [bystanders or EMS] or chest compressions).
  • Exclusions: Aged less than 18 years, do-not-resuscitate order being discovered, transport prior to cardiac arrest, missing data to classify as intra-arrest or to classify the primary outcome, missing variables required for propensity score analysis.
• Intervention: Intra-arrest transport prior to any episode of ROSC defined as palpable pulse for any duration.
• Comparison: Continued on-scene resuscitation.
• Outcome:
  • Primary Outcome: Survival to hospital discharge.
  • Secondary Outcomes: Survival with favorable neurologic outcome (defined as a modified Rankin scale [mRS] score of less than three).
• Type of Study: Multi-center (192 EMS agencies) observational study.

Authors’ Conclusions

Among patients experiencing out-of-hospital cardiac arrest, intra-arrest transport to hospital compared with continued on-scene resuscitation was associated with lower probability of survival to hospital discharge. Study findings are limited by potential confounding due to observational design.

Results

The included population consisted of 43,969 patients. The median age was 67 years, two-thirds were male, and half were bystander- or EMS-witnessed. Of these OHCAs, 22 percent had an initial shockable rhythm and one-quarter underwent intra-arrest transport.