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Assessment of emergency physicians’ performance in identifying shockable rhythm in out-of-hospital cardiac arrest: an observational simulation study
  1. Clément Derkenne1,
  2. Daniel Jost1,
  3. Florian Roquet2,
  4. Pascal Corpet3,
  5. Benoit Frattini1,
  6. Romain Kedzierewicz1,
  7. Guillaume Bellec4,
  8. Benjamin Rajon5,
  9. Marianne Fernandez6,
  10. Thomas Loeb7,
  11. Emmanuel Pierantoni8,
  12. Antoine Lamblin9,
  13. Bertrand Prunet1,10
  14. on behalf of the Paris Fire Brigade Cardiac Arrest Task Force
    1. 1 Paris Fire Brigade, Paris, France
    2. 2 Anesthesia and Critical Care Department, Hôpital européen Georges-Pompidou, Paris, France
    3. 3 Bayes Impact, Paris, France
    4. 4 Marseille Naval Fire Battalion, Marseille, France
    5. 5 Emergency Department, CHU de La Réunion Sites Sud Saint-Pierre, Saint-Pierre, Réunion
    6. 6 Service d'Aide Médicale d'Urgence, Gap, France
    7. 7 Service d'Aide Médicale d'Urgence, Garches, France
    8. 8 Emergency Department, Hopital de Saint-Jean de Maurienne, Saint Jean de Maurienne, France
    9. 9 Hopital d'Instruction des Armees Percy, Clamart, France
    10. 10 Ecole du Val-de-Grace, Paris, France
    1. Correspondence to Dr Clément Derkenne, Paris Fire Brigade, Paris, France; clement.derkenne{at}gmail.com

    Abstract

    Background Emergency physicians can use a manual or an automated defibrillator to provide defibrillation of patients who had out-of-hospital cardiac arrest (OHCA). Performance of emergency physicians in identifying shockable rhythm with a manual defibrillator has been poorly explored whereas that of automated defibrillators is well known (sensitivity 0.91–1.00, specificity 0.96–0.99). We conducted this study to estimate the sensitivity/specificity and speed of shock/no-shock decision-making by prehospital emergency physicians for shockable or non-shockable rhythm, and their preference for manual versus automated defibrillation.

    Methods We developed a web application that simulates a manual defibrillator (https://simul-shock.firebaseapp.com/). In 2019, all (262) emergency physicians of six French emergency medical services were invited to participate in a study in which 60 ECG rhythms from real OHCA recordings were successively presented to the physicians for determination of whether they would or would not administer a shock. Time to decision was recorded. Answers were compared with a gold standard (concordant answers of three experts). We report sensitivity for shockable rhythms (decision to shock) and specificity for non-shockable rhythms (decision not to shock). Physicians were also asked whether they preferred manual or automated defibrillation.

    Results Among 215 respondents, we were able to analyse results for 190 physicians. 57% of emergency physicians preferred manual defibrillation. Median (IQR) sensitivity for a shock delivery for shockable rhythm was 0.91 (0.81–1.00); median specificity for no-shock delivery for non-shockable rhythms was 0.91 (0.80–0.96). More precisely, sensitivities for shock delivery for ventricular tachycardia (VT) and coarse ventricular fibrillation (VF) were both 1.0 (1.0–1.0); sensitivity for fine VF was 0.6 (0.2–1). Specificity for not shocking a pulseless electrical activity (PEA) was 0.83 (0.72–0.86), and for asystole, specificity was 0.93 (0.86–1). Median speed of decision-making (in seconds) were: VT 2.0 (1.6–2.7), coarse VF 2.1 (1.7–2.9), asystole 2.4 (1.8–3.5), PEA 2.8 (2.0–4.2) and fine VF 2.8 (2.1–4.3).

    Conclusions Global sensitivity and specificity were comparable with published automated external defibrillator studies. Shockable rhythms with the best clinical prognoses (VT and coarse VF) were very rapidly recognised with very good sensitivity. The decision-making for fine VF or asystole and PEA was less accurate.

    • theraputics
    • arrhythmias

    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplemental information. The simulator used for this work is now freely available. It gives access to the results immediately after answering the simulations: https://simul-shock.firebaseapp.com/.

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    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplemental information. The simulator used for this work is now freely available. It gives access to the results immediately after answering the simulations: https://simul-shock.firebaseapp.com/.

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    Footnotes

    • Handling editor Caroline Leech

    • Collaborators Daniel Jost; Frederic Lemoine; Vincent Lanoe; Benoit Frattini; Eric Gauyat; Sabine Lemoine; Frederic Briche; Xavier Lesaffre; Laure Alhanati; Jean-Paul Freiermuth; Romain Kedzierewicz; Albane Miron De L’espinay; Ludovic Delhaye; Olga Maurin; Clément Derkenne; Romain Jouffroy; Laurent Prieux; Olivier Yavari; Vivien Hong; Olivier Stibbe; Stéphane Travers; Bertrand Prunet.

    • Contributors CD, DJ and FR designed the study. PC, BF, GB, DJ, MF, EP, TL, RK, VH and FB helped the acquisition of data. FR, BF, CD, AL, BP and DJ helped the analysis and the interpretation of data. CD, DJ, FR, PC, BF, GB, MF, EP, TL, RK, AL, BP, VH and FB drafted the article or revised it critically for important intellectual content and approved the version to be submitted. CD is responsible for the overall content as the guarantor.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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