EARLY DEFIBRILLATION BY EMERGENCY PHYSICIANS OR EMERGENCY MEDICAL TECHNICIANS - PROSPECTIVE, COMPARATIVE MULTICENTER STUDY

In a controlled prospective randomized study, defibrillation by emergency medical technicians (EMTs) was compared with the current standard of care in Germany (basic life support by EMTs and defibrillation by emergency physicians only) in order to answer the following questions: 1. Does EMT defibrillation improve the survival rate and long-term prognosis of patients in ventricular fibrillation as compared to the current German standards in resuscitation (basic life support by EMTs and defibrillation by emergency physicians)? 2. Are the prerequisites for the use of semiautomatic defibrillators fulfilled in the emergency medical systems (EMS) of the participating centers? Methods. The study phase includes randomization of 121 adult patients with witnessed cardiac arrest and ventricular fibrillation (VF) as first ECG rhythm. Prior to the onset of the study, all EMTs of the participating EMS systems were retrained in basic life support (BLS) measures. In each center, randomly assessed EMT-Ds (EMTs trained in Defibrillation) were trained to use semiautomatic defibrillators. With the help of one-line tape recording, the time intervals during resuscitation and treatment steps were evaluated. Successfully resuscitated patients were followed up with the help of the Glascow Coma Scale and the Pittsburgh Cerebral and Overall Performance Categories. Results. From 1 February 1991 until 28 June 1992, 159 patients with VF were randomized. In 121 cases, collapse was witnessed. 25% (14/57) of the patients receiving defibrillation by EMT-Ds (study group = S) were discharged from the hospital alive. In the control group, 52 patients were defibrillated by emergency physicians, following BLS by EMTs [control group 1=C1; discharged: 29% (15/52)]. Fifty patients received BLS and advanced cardiac life support (ACLS) by the emergency physicians crews [control group 2=C2; discharged: 18% (9/50)]. In the study group, the median time interval from collapse of the patient until initiation of BLS measures was 7.7 min, 7 min in C1 and 8 min in C2. ACLS measures were initiated significantly earlier (P<0.05) in the control groups, as compared to the study group [S:13 min, C1:11 min; C2: 10.3 min]. Sixty-seven percent (30/45) of the study patients and 46% (36/76) of the control patients were defibrillated within 12 min. Study patients were defibrillated earlier (P<0.05) (S:9.9 min; C1:12.2 min; C2:12.75 min); return of spontaneous circulation (ROSC) was achieved earlier (P<0.05) in the study group [S:14 min; C1:19 min; C2:18.2 min] and the number of patients in the study group requiring no epinephrine during resuscitation was higher (P<0.01) than in the control groups [S:35.3% (12/34); Cl:10% (4/40); C2:10.5% (4/38)]. Furthermore, the total amount of epinephrine [mean (+/- standard error)] administered in the study group [S: 2.35 (+/- 0.49) mg; Cl:6.71 (+/-0.98) mg; C2: 7.71 (+/-1.31) mg] was significantly lower (P<0.05). No significant differences in neurological long-term prognosis were found for the groups investigated. Conclusion. Neither the initial survival rate the number of patients discharged alive, nor the neurological long-term prognosis was significantly different for any of the groups investigated. Because of apparent differences in indirect prognostic parameters (time interval until ROSC, number of patients requiring no epinephrine) and because of the fact that the time interval to the first defibrillation was reduced by EMT defibrillation, EMT-Ds may perform defibrillation if: (a) they reach the patient before the emergency physician and (b) if they are trained intensively and supervised continuously. In order to increase the efficiency of defibrillation by EMT-Ds, far-reaching changes in our EMS are mandatory: (a) a reduction in the time interval from collapse until initiation of BCLS measures by intensifying layperson CPR training; (b) an increase in the number of emergency units equipped with semiautomatic defibrillators; (c) the consistent implementation of a tiered EMS.