Effects of COVID-19 pandemic on out-of-hospital cardiac arrests: A systematic review

Abstract

Introduction In addition to the directly attributed mortality, COVID-19 is also likely to increase mortality indirectly. In this systematic review, we investigate the direct and indirect effects of COVID-19 on out-of-hospital cardiac arrests. Methods We searched PubMed, BioMedCentral, Embase and the Cochrane Central Register of Controlled Trials for studies comparing out-of-hospital cardiac arrests occurring during the pandemic and a non-pandemic period. Risk of bias was assessed with the ROBINS-I tool. The primary endpoint was return of spontaneous circulation. Secondary endpoints were bystander-initiated cardiopulmonary resuscitation, survival to hospital discharge, and survival with favourable neurological outcome. Results We identified six studies. In two studies, rates of return of spontaneous circulation and survival to hospital discharge decreased significantly during the pandemic. Especially in Europe, bystander-witnessed cases, bystander-initiated cardiopulmonary resuscitation and resuscitation attempted by emergency medical services were reduced during the pandemic. Also, ambulance response times were significantly delayed across all studies and patients presenting with non-shockable rhythms increased in two studies. In 2020, 3.9-5.9% of tested patients were SARS-CoV-2 positive and 4.8-26% had suggestive symptoms (fever and cough or dyspnoea). Conclusions Out-of-hospital cardiac arrests had worse short-term outcomes during the pandemic than a non-pandemic period suggesting direct effects of COVID-19 infection and indirect effects from lockdown and disruption of healthcare systems. Patients at high risk of deterioration should be identified outside the hospital to promptly initiate treatment and reduce fatalities. Study registration PROSPERO CRD42020195794.

Influence of COVID-19 pandemic on bystander interventions, emergency medical service activities, and patient outcomes in out-of-hospital cardiac arrest in Osaka City, Japan

“…In contrast to Lombardy, Italy, and Paris, France, where a drastic decrease in OHCA survival rate has been reported, 2 , 3 patient outcomes were maintained during the pandemic study period, similar to findings in the Province of Padua, Northeast Italy, and Bologna, Italy. 9 , 10 Consistent with previous studies, 11 , 12 fewer patients received endotracheal intubation in Osaka City because of changing EMS protocols. Scene times did not differ between periods; however, the response time and hospital arrival time were shorter during the COVID-19 period.…”

“…These results were in contrast to previously reported data that the response time was longer during the COVID-19 pandemic period. 11 , 12 One possible explanation is traffic reduction owing to the stay home policy. Elmer et al showed there were no differences in the provision of laypersons, AED use, and prehospital return of spontaneous circulation in areas with a low COVID-19 prevalence.…”

COVID-19 and the global OHCA crisis: An urgent need for system level solutions

“…In this edition of Resuscitation, two systematic reviews 1 , 2 and a national Spanish cohort study 3 highlight the alarming impact of the COVID-19 pandemic on the management and outcomes of out-of-hospital cardiac arrest (OHCA). The rapidly increasing literature in this area is highlighted by the difference in the number of identified studies between the two systematic reviews, despite only a small difference in search dates.…”

“…In some patients, the OHCA may be precipitated by hypoxic respiratory failure. 9 This might also explain, in part, the lower rate of shockable rhythms documented in the pandemic OHCA cohorts 1 , 2 and may also have implications regarding the utility of providing ‘hands only’ bystander CPR in these patients. Additionally, SARS-CoV infection has also been documented to cause myocarditis, 10 arrythmias, 11 and a hyper-coagulable state leading to thrombotic events including cerebral vascular accidents.…”

“… 20 , 21 , 22 The requirement to wear this PPE was identified as leading to potential delays in both the dispatch process as well as the medical response. 2 This concern may also have contributed to reduced incidence of bystander CPR. 23 While important to protect clinicians from the additional risk potentially associated with treating an infectious patient in cardiac arrest, 24 much uncertainty remains regarding the specific risk associated with various treatments and interventions delivered during a resuscitation 25 and in particular the most appropriate mitigation strategies for use in the pre-hospital setting.…”