Regional Emergency Medicine and Prehospital Care Evaluated in 10-year review of D. O. A Cases

To evaluate on-the-scene first aid and paramedical management of emergency cases and to assess the preliminary emergency care provided by regional hospital, we reviewed the records of the patients brought dead on arrival (D. O. A.) to Kitasato University Hospital (KUH) between June 1979 and March 1990. In the period cited (10 yr 10 mo), 682 patients were presented D. O. A., a term explicitly defined as a person with no respiration and no palpable pulse and/or whose electrocardiogram showed standstill, ventricular fibrillation or electromechanical dissociation at the time of arrival. Patients at the terminal stage of nonreversible illness were excluded from the D. O. A. category. The following considerations were investigated : the cause of cardiac arrest, bystander administration of cardiopulmonary resuscitation (CPR), interval required for emergency personnel to arrive, time required for transportation to KUH, and treatment at a regional hospital enroute KUH. Endogenously derived causes accounted for 65.2% (445) of the D. O. A. cases, whereas injury or some other exogenous event was involved in 34.8% (237). The most predominant diseases seen in the endogenous group were those of the cardiovascular system (48.8%), and most frequent type of exogenous casualty was multiple trauma (73. 0%). An average of 6.1±3.9 min lapsed before emergency personnel arrived on the scene. On arrival of emergency personnel, cardiac arrest was found in 551 (80.8 %) cases and no cardiac arrest in 131 (19.2%). CPR had been administered by a bystander in 42 (8.3%) of the patients showing no vital signs (cardiac arrest). Transportation to KUH took about 20.0±9.0min. Of 52 patients initially taken to a regional hospital then proceeding to KUH, 43 (82.7%) had cardiac arrest on the way to KUH. In 15 (34.9%) of those with cardiac arrest enroute, advanced life support (ALS) had been provided at the regional hospital. Altogether 23 (3.4%) of the patients termed D. O. A. survived, 11 regaining consciousness and returning home and 12 left with severe neurological impairment. Of the 11 patients recovering without adverse effect, 1 showed no vital signs at the scene of the emergency whereas 10 had palpable pulse and respiration when the emergency personnel arrived on the scene. Moreover, all 10 received ALS resuscitation within 5 min of confirmation of cardiac arrest enroute to KUH. In the present review, effective preliminary care, particularly the expedient administration of CPR, was crucial to the survival of the patients in life-threatening emergencies. These result show the need for upgrading the training of emergency personnel and for improving the emergency systems of regional hospitals as vital procedures in the management of patients termed D. O. A. and as steps to increase the chance of patient survival.