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Fig. 1

Flow diagram of the study population. A total of 16,452 CA patients were enrolled in the SOS-KANTO 2012 study. Of these, 13,597 adult patients had initially nonshockable rhythms. Of these, 11,481 patients were evaluated in this study. Of these, 10,960 patients received no shock (Subsequently Not Shocked group) and 521 patients received shock(s) during EMS resuscitation (Subsequently Shocked group). survival with favorable neurological outcome defined as Cerebral Performance Category of 1 or 2 at 1 month after CA, emergency medical service, return of spontaneous circulation

EMS providers collected prehospital information in the standardized Utstein style, including age, sex, location, witnessed arrest, bystander CPR, call–response interval, initial cardiac rhythms monitored by EMS providers, and shock deliveries by EMS providers. We defined rhythm conversion of nonshockable rhythms to VF/ pulseless VT during EMS resuscitation when EMS providers delivered shock(s) for patients who had initially nonshockable rhythms; we used shock delivery as a surrogate indicator of conversion [ 11 , 12 , 14 , 15 , Hush Puppies Fraulein Mariya Wedge SlipOn Womens DaVRF
,
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]. The call–response interval was defined as the interval from receipt of a call by emergency response dispatchers to the time when the emergency response vehicle came to a stop. Shock delivery time was defined as the interval between the initiation of CPR by EMS providers and the time of first shock delivery by EMS providers.

Patients who had initially nonshockable rhythms and subsequently received shock(s) during EMS resuscitation were assigned to the “Subsequently Shocked” group, while other patients who did not receive subsequent shock by EMS providers were assigned to the “Subsequently Not Shocked” group. EMS providers used semiautomated external defibrillators to analyze the rhythm, and if a shock was indicated it was delivered [ 19 ].

Physicians were responsible for treating the patient-determined causes of CA, including cardiac and noncardiac (asphyxia, trauma, aortic disease, drawing, cerebrovascular disease, drug overdose, and others). The institutional researchers collected information that included ROSC during resuscitation by EMS providers or physicians, 24-hour survival, 1-month survival, and neurological outcomes. Neurological outcomes were evaluated using the Cerebral Performance Categories (CPCs) [ 20 ]; responses were scored as follows: CPC 1, good cerebral performance; CPC 2, moderate cerebral disability; CPC 3, severe cerebral disability; CPC 4, coma/vegetative state; and CPC 5, death. Favorable neurological outcome was defined as CPC 1 or 2.

The primary outcome variable was 1-month survival with a favorable neurological outcome. For the primary analysis, we assessed differences in 1-month favorable neurological outcomes by subsequent shock delivery using a multivariate logistic regression to allow for adjustment for potential confounding factors reported previously, including age, sex, public location, witnessed arrest, bystander CPR, call–response interval, initial PEA rhythm, and cardiac etiology as covariates [ 11 , 12 , 14 , 15 , 16 , 17 ]. For the secondary analysis, we used a multivariate logistic regression to assess factors associated with the presence of subsequent shock. In addition, the frequency of ROSC, 24-hour survival, 1-month survival, and 1-month favorable neurological outcome in subsequent shock patients were compared by interval of EMS shock delivery. Odds ratios (ORs) and 95 % confidence intervals (CIs) were calculated. The level of significance was set at α = 0.05 with a two-tailed test. Analyses were performed using SPSS (version 21; SPSS, Chicago, IL, USA) statistical software packages.

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