Background: The outcome of cardiac arrest and CPR is dependent on critical interventions, particularly early defibrillation, effective chest compressions and assisted ventilation. Utstein-style definitions and reporting templates have been used extensively in published studies of cardiac arrest, which has led to greater understanding of the elements of resuscitation practice and progress towards resuscitation guidelines. Objective: To determine how well CPR is utilized at our institution and to identify key predictors of post CPR outcome by analyzing in-hospital cardiac arrest data collected using the Utstein template based form. Methods: 150 patients of in-hospital cardiac arrest, from April 2015 up to 18 months, including patients with cardiac arrest announced through code blue were studied. Patients with cardiac arrest were resuscitated according to ACLS guidelines and data was recorded in the proforma according to utstein template. Those patients with return of spontaneous circulation (ROSC) were followed up at the time of discharge and after 6 months for survival. Result: Mean age of patients with cardiac arrest was Mean ±SD: 57.02±16.76. Out of 102 cardiac arrest cases on which defibrillation was attempted, for 80 patients defibrillation was attempted within 1-10secs, that is nearly 78.4%, which had an a significant impact on the outcome. Out of 150 cases of cardiac arrest, 65 patients had initial rhythm of ventricular fibrillation of which 56 patients were alive at the time of discharge and 9 patients could not be revived. Nearly 30 patients had an initial rhythm of asystole of which only 10 patients that is 10.8% were alive and 20 patients that is 35.1% could not be revived. Only 2 patients that are 2.2% having PEA as initial rhythms were alive at the time of discharge and 18 patients that is 31.6% could not be revived. The survival at discharge was higher for patients with VF than asystole and PEA. Out of total 104 cases in which defibrillation were attempted 84 patients were alive at discharge that is nearly 90.3% and 20 patients were not revived which is 35.1%. Survival status at discharge was significant in patients in whom chest compressions was started within 1-5seconds. Patients in whom defibrillation was attempted at the earliest had better survival. Hence proves the importance of early intervention, effective chest compression and rapid defibrillation. Out of 150 patients, 94 patients achieved return of spontaneous circulation out of which 93 patients were alive up to discharge that is 127.4% and 1 patient did not survive up to discharge that is 5.3%. Out of 65 patients with VF, 56 patients achieved return of spontaneous circulation that is 59.6%. Out of total 30 patients with asystole, 10 patients achieved return of spontaneous circulation that is 10.6% and 20 patients did not achieve return of spontaneous circulation that is 35.7%. Conclusion: The most common cardiac arrest rhythm with better outcome was ventricular fibrillation. Asystole and PEA had a poor outcome inspite of early and effective chest compressions. Patients with early defibrillation had a higher survival rate at discharge with a CPC-3 followed by CPC-2, hence proving the importance of rapid defibrillation being a critical intervention during resuscitation. Patients achieving ROSC had a better survival to discharge, which gradually declined after 6months of follow up. Patient with shockable rhythm, early chest compression and rapid defibrillation had higher incidence of achieving ROSC.
Cardiac arrest is a dynamic disease that tests the multitasking and leadership abilities of emergency physicians. Providers must simultaneously manage the logistics of resuscitation while searching for the cause of cardiac arrest. The astute clinician will also realize that he or she is orchestrating only one portion of a larger series of events, each of which directly affect patient outcomes. Resuscitation science is rapidly evolving, and emergency providers must be familiar with the latest evidence and controversies surrounding resuscitative techniques.1
The cause of cardiac arrest in the inpatient environment is highly variable, which likely contributes to the lower success rates for resuscitation seen as compared with the outpatient environment.2 Overall survival of in-hospital cardiac arrest has remained largely unchanged over the last 40 years. Modest improvement recently seen likely reflects improved documentation and reporting and a more restrictive approach to the use of cardiopulmonary resuscitation (CPR). Nonetheless, although overall survival is low, almost 60% of those who survive have good neurological recovery at the time of hospital discharge.3
In patient cardiac arrest data also includes those patients in the end stages of non cardiac disease who present with shock, respiratory failure and apnoea, leading to bradycardia, pulseless electrical activity and asystole. These patients are less likely to respond to CPR and defibrillation and have poor overall prognosis. The enthusiasm for development of rapid response teams (also known as code blue team or medical emergency team) stems from the observation that patients often exhibit signs of physiological deterioration prior to cardiopulmonary resuscitation. Success of these systems will depend on ongoing education, organisational support, meticulous data collection, review and ongoing feedback.4
The outcome of cardiac arrest and CPR is dependent on critical interventions, particularly early defibrillation, effective chest compressions and assisted ventilation. If patient outcomes are to improve evaluation of the contribution of all potential risk factors and interventions is essential. To improve this situation, international resuscitation council task forces, now known as the international liaison committee on resuscitation (ILCOR), published a series of guidelines for uniform reporting of adult out-of-hospital, adult-in-hospital resuscitation and resuscitation education. The Utstein templates which was developed for this purpose, defines variables that are essential for uniform documenting and reporting of cardiac arrest and its outcomes.6
Utstein-style guidelines contribute to improved public health internationally by providing a structured framework to compare with emergency medical services systems. Advances in resuscitation science, new insights into important predictors of outcome from in-hospital cardiac arrest, and lessons learned from methodological research prompted this review and update of the 2004 Utstein guidelines. Representatives of the (ILCOR) developed an updated Utstein reporting framework iteratively by meeting face to face, by teleconference, and by Web survey during 2012 through 2014. Herein are recommendations for reporting in-hospital cardiac arrest. Data elements were grouped by system factors, dispatch/recognition, patient variables, resuscitation/post resuscitation processes, and outcomes. Elements were classified as core or supplemental using a modified Delphi process primarily based on respondent’s assessment of the evidence-based importance of capturing those elements, tempered by the challenges to collect them. New or modified elements reflected consensus on the need to account for emergency medical services system factors, increasing availability of automated external defibrillators, data collection processes, epidemiology trends, increasing use of dispatcher-assisted cardiopulmonary resuscitation, emerging field treatments, post resuscitation care, prognostication tools, and trends in organ recovery. A standard reporting template is recommended to promote standardized reporting. This template facilitates reporting of the bystander-witnessed, shockable rhythm as a measure of emergency medical services system efficacy and all emergency medical services system-treated arrests as a measure of system effectiveness. Several additional important subgroups are identified that enable an estimate of the specific contribution of rhythm and bystander actions that are key determinants of outcome.6
In the present study, we sought to determine how well CPR is utilized at our institution and to identify key predictors of post CPR outcome by analyzing in-hospital cardiac arrest data collected using the Utstein template based form
The study was a single arm observational study that included 150 cases of cardiac arrest, both in-patient and out-patient of all departments in the hospital, in Apollo hospital, Bannerghatta Road, Bengaluru.
INCLUSION CRITERIA:
EXCLUSION CRITERIA:
STUDY METHODOLOGY:
Apollo hospital is comprised of a code blue team which is dedicated for resuscitation of all cardiac arrest patients. The team comprises of general physician, anaesthetist, cardiologist and emergency physician along with floor in-charge nurse, patient in-charge nurse and ward security. All the floors of the hospital are well equipped with a crash cart containing all life saving drugs which can be easily accessible during the time of arrest. The crash cart is checked on a regular basis by pharmacy in-charge and drugs used during resuscitation are replaced immediately. Once patient arrests in any part of the hospital except operation theatre, emergency room and intensive care unit, there is a call for the code blue team. The cardiac arrest patients in operation theatres, emergency room and intensive care unit are immediately attended by the respective code blue team members present. The team reaches within 60-90seconds to the site where the patient arrests and immediately initiates CPR as per the ACLS guidelines. The team performs resuscitation till the patient is shifted to emergency or ICU. On arrival, patient will be checked for return of spontaneous circulation.
Patient will be followed up for a period of 6 months along with the neurological status/ cerebral performance category (CPC) at the time of discharge and at 6months. The cerebral performance category is an indicator of outcome of brain injury. The CPC is classified as following:
CPC 1- good cerebral performance: conscious, alert, able to do work and lead a normal life.
CPC 2- Moderate cerebral disability: conscious, sufficient cerebral function for part time work in sheltered environment or independent activities of daily life.
CPC 3- Severe cerebral disability: conscious, dependent on others for daily support because of impaired brain function.
CPC 4- coma, vegetative state, not conscious
CPC 5- certified brain dead
DATA COLLECTION METHOD:
Data will be collected using the revised Utstein template during the time patient is resuscitated. This form will be completed by the resuscitation lead involved in the resuscitation attempt. Utstein-style guidelines contribute to improved public health by providing a structured framework which helps in comparison with emergency medical services systems. Data elements were grouped by system factors, dispatch/recognition, patient variables, resuscitation/post resuscitation processes, and outcomes. Elements were classified as core or supplemental using a modified Delphi process. The core data is data without which analysis and comparisons would be difficult or meaningless. These data are generally easier to collect. Supplementary data are more comprehensive and more specific and should be reported whenever possible. However they are generally more difficult to collect and tend to be less precise than core data. New or modified elements reflected consensus on the need to account for emergency medical services system factors, increasing availability of automated external defibrillators, data collection processes, epidemiology trends, increasing use of dispatcher-assisted cardiopulmonary resuscitation, emerging field treatments, post resuscitation care, prognostication tools, and trends in organ recovery.1
STUDY ANALYSIS:
All data from the study proforma sheets were entered into an electronic spreadsheet that would facilitate data analysis, data visualization and report generation. Descriptive statistics shall be presented for all study patients and subgroup analysis shall be done on the basis of age, sex and risk factors.
There were a total of 150 cardiac arrest cases, maximum number of cases were in the age group 61-70years. Nearly a quarter numbers of cases were between age group of 71-90years, with oldest patient being of 86years. Nearly a 50% of cases were between the age group of 20-60years with the youngest patient aged about 19years.
Out of 150 cases, 90 were male and 60 were female population, with 60% and 40% respectively.
Out of 150 cardiac arrest cases studied, maximum male and female population belonged to age group 61-70years, which is nearly 24.7%. Age group less than 20 years contributed to 1% and 80-90years age group contributed to 4%.
In this study 52% of the total 150 cases were diabetic, 58.7% of the total cases were found to have hypertension, 22% of the total 150 cases were chronic kidney disease patients and 35.3% of total cases were having ischemic heart disease.
Table 1: Location of arrest distribution of patients studied
Location of arrest |
Gender |
Total |
|
Female |
Male |
||
Emergency |
21(35%) |
40(44.4%) |
61(40.7%) |
ICU |
13(21.7%) |
12(13.3%) |
25(16.7%) |
OPD |
7(11.7%) |
12(13.3%) |
19(12.7%) |
WARD |
7(11.7%) |
12(13.3%) |
19(12.7%) |
Cathlab |
4(6.7%) |
7(7.8%) |
11(7.3%) |
Dialysis room |
6(10%) |
5(5.6%) |
11(7.3%) |
Oncology dept |
2(3.3%) |
2(2.2%) |
4(2.7%) |
Total |
60(100%) |
90(100%) |
150(100%) |
P=0.725, Not significant, Fisher Exact test
Out of 150 cases studied, about 40.7% cases arrested in emergency department followed by
16.7% cases which arrested in the intensive care unit (ICU). The least number of cardiac arrest cases were located in oncology department, about 2.7%.
Out of 150 cases of cardiac arrest cases studied, 87.3% were witnessed cardiac arrest and about 12.7% cases were un-witnessed cardiac arrest cases.
Table 2: Initial Rhythm distribution of patients studied
Initial Rhythm |
Gender |
Total |
|
Female |
Male |
||
Ventricular fibrillation |
26(43.3%) |
39(43.3%) |
65(43.3%) |
Ventricular tachycardia |
14(23.3%) |
21(23.3%) |
35(23.3%) |
Asystole |
13(21.7%) |
17(18.9%) |
30(20%) |
Pulse less electrical activity |
7(11.7%) |
13(14.4%) |
20(13.3%) |
Total |
60(100%) |
90(100%) |
150(100%) |
P=0.951, Not significant, Chi-Square test
Out of 150 cardiac arrest cases studied, 43.3% of cases the initial cardiac arrest rhythm was ventricular fibrillation, 23.3% cases the rhythm was pulseless ventricular tachycardia, 20% cases the rhythm was asystole and 13.3% cases the rhythm was pulseless electrical activity.
Out of 150 cardiac arrest cases studied, 120 cases were initiated with chest compressions within 1-5secs which is 80.5%, followed by 10 cases which were initiated with chest compressions within 6-10secs which is 6.7%. Only 2 cases were initiated with chest compressions after 40secs which is almost 1.3%
Table 3: Defibrillation attempted
Defibrillation attempted |
Gender |
Total |
|
Female |
Male |
||
No |
18(30%) |
28(31.1%) |
46(30.7%) |
Yes |
42(70%) |
62(68.9%) |
104(69.3%) |
Total |
60(100%) |
90(100%) |
150(100%) |
P=0.885, Not significant, Chi-Square test
Out of 150 cases studied, 104 cases were attempted with defibrillation, which is 69.3% and 46 cases defibrillation was not attempted which is nearly 30.7%. All the cases in which defibrillation was attempted were shockable rhythms and rest were non-shockable rhythms.
Table 4: Defibrillation attempted Interval
Defibrillation attempted Interval |
Gender |
Total |
|
Female |
Male |
||
1-10 |
38(90.5%) |
42(70.0%) |
80(78.4%) |
11-20 |
3(7.1%) |
5(8.3%) |
8(7.8%) |
21-30 |
1(2.4%) |
7(11.7%) |
8(7.8%) |
31-40 |
0(0%) |
6(10%) |
6(5.9%) |
Total |
42(100%) |
60(100%) |
102(100%) |
P=0.036*, significant, Fisher Exact test
Out of 102 cardiac arrest cases on which defibrillation was attempted, for 80 patients defibrillation was attempted within 1-10secs, that is nearly 78.4%, which had an a significant impact on the outcome.
Out of 150 cases studied 148 cases were put on ventilation, that is 98.7% and only 2 cases were not attempted with ventilation, which is nearly 1.3%.
All 150 cases of cardiac arrest, all of them were treated with drugs. All 150 cardiac arrest cases were treated with injection epinephrine at the time of resuscitation which accounts to 100%.
Nearly 91 cases required injection epinephrine at frequency of 3-5times, which is nearly 60.7%. Only 21 patients required injection epinephrine at frequency 6-10, which is nearly 14%.
Nearly 86 patients out of 150 required injection amiodarone, which are nearly 57.3% and 64 patients was not administered with injection amiodarone, which are nearly 42.7%
Out of 150 cardiac arrest cases resuscitated only 94 achieved return of spontaneous circulation, which are about 62.7% and 56 did not achieve return of spontaneous circulation which are about 37.3%.
Table 5: Neurological status at discharge distribution of patients studied
Neurological status at discharge |
Gender |
Total |
|
Female |
Male |
||
No |
23(38.3%) |
33(36.7%) |
56(37.3%) |
Yes |
37(61.7%) |
57(63.3%) |
94(62.7%) |
· CPC-1 |
2(3.3%) |
7(7.8%) |
9(6%) |
· CPC-2 |
12(20%) |
22(24.4%) |
34(22.7%) |
· CPC-3 |
20(33.3%) |
18(20%) |
38(25.3%) |
· CPC-4 |
3(5%) |
10(11.1%) |
13(8.7%) |
P=0.836, not significant, Chi-Square test
Out of 150 cases, 94 patients achieved return of spontaneous circulation of which 38 patients belonged to CPC-3 that is 25.3%, 34 patients belonged to CPC-2 that is 22.7%, 13 patients belonged to CPC-4 that is 8.7% and only 9 patients belonged to CPC-1 that is 6%. 56 patients did not achieve return of spontaneous circulation.
Out of 150 cases studied 94 patients were alive at discharge that is 62.7% and 56 patients could not be revived that is 37.3%.
Out of the patients alive at discharge, 73 patients were alive after 6 months from discharge which is 79.3% and 19 patients were dead after 6 months from discharge that is nearly 20.7%.
Table 6: Initial Rhythm in relation to survival status at discharge
Initial Rhythm |
Survival of Status Discharge |
Total |
|
Alive |
Dead |
||
VF |
56(60.2%) |
9(15.8%) |
65(43.3%) |
VT |
25(26.9%) |
10(17.5%) |
35(23.3%) |
Asystole |
10(10.8%) |
20(35.1%) |
30(20%) |
PEA |
2(2.2%) |
18(31.6%) |
20(13.3%) |
Total |
93(100%) |
57(100%) |
150(100%) |
P<0.001**, significant, Chi-Square test
Out of 150 cases of cardiac arrest, 65 patients had initial rhythm of ventricular fibrillation of which 56 patients were alive at the time of discharge and 9 patients could not be revived. Nearly 30 patients had an initial rhythm of asystole of which only 10 patients that is 10.8% were alive and 20 patients that is 35.1% could not be revived. Only 2 patients that are 2.2% having PEA as initial rhythms were alive at the time of discharge and 18 patients that is 31.6% could not be revived. Thus patients with ventricular fibrillation had a better outcome and asystole and PEA had a poor outcome.
Table 7: Initial Rhythm in relation to survival status at 6 months
Initial Rhythm |
Survival of Status 6 months |
Total |
|
Alive |
Dead |
||
VF |
43(58.9%) |
12(63.2%) |
55(59.8%) |
VT |
21(28.8%) |
4(21.1%) |
25(27.2%) |
Asystole |
8(11%) |
2(10.5%) |
10(10.9%) |
PEA |
1(1.4%) |
1(5.3%) |
2(2.2%) |
Total |
73(100%) |
19(100%) |
92(100%) |
P=0.617, Not significant, Fisher Exact test
Out of 55 cases of ventricular fibrillation 43 survived after 6months from discharge which is 58.9%. Out of 10 cases of asystole, 8 survived after 6 months from discharge which is 11% and 2 patients did not survive at the end of 6 months that is 10.5%.
Out of total 104 cases in which defibrillation were attempted 84 patients were alive at discharge that is nearly 90.3% and 20 patients were not revived which is 35.1%. out of total 46 cases in which defibrillation was not attempted only 9 patients were alive at discharge which is nearly 9.7% and 37 patients were dead at discharge which is nearly 64.9%.
Out of 83 patients on whom defibrillation was attempted, 67 patients were alive after 6 months from discharge that is 91.8% and 16 patients did not survive upto 6 months after discharge that is 84.2%. Out of total 9 patients on whom defibrillation was not attempted 6 patients were alive after 6 months from discharge that is 8.2% and 3 patients did not survive upto 6 months after discharge that is 15.8%.
Survival status at discharge was significant in patients in whom chest compressions was started within 1-5seconds. Patients in whom defibrillation was attempted at the earliest had better survival. Hence emphasizes the importance of early intervention, effective chest compression and rapid defibrillation.
Out of 150 patients, 94 patients achieved return of spontaneous circulation out of which 93 patients were alive up to discharge that is 127.4% and 1 patient did not survive upto discharge that is 5.3%. Out of total 56 patients in who return of spontaneous circulation is not achieved all 56 did not survive at the time of discharge that is 294.7%.
Out of 65 patients with VF, 56 patients achieved return of spontaneous circulation that is 59.6%. Out of total 30 patients with asystole, 10 patients achieved return of spontaneous circulation that is 10.6% and 20 patients did not achieve return of spontaneous circulation that is 35.7%. Hence ventricular fibrillation has a better outcome when compared to asystole in cardiac arrest.
Out of 150 cardiac arrest cases, 61 cases the etiology was due to a cardiac cause that is 40.7%. 38 cases were cardiac and respiratory arrest that is 25.3% and 35 cases were due to respiratory cause which is 23.3%
Out of 61 cardiac arrest cases, 42 patients survived up to discharge that is 45.2%. Out of 38 cardiac and respiratory arrest cases 21 patients survived up to discharge that is 22.6% and out of 35 respiratory arrest cases 21 patients survived up to discharge that is nearly 22.6%.
Out of 61 patients with cardiac arrest 43 patients return of spontaneous circulation was achieved that is nearly 45.7%. For both cardiac and respiratory arrest and respiratory arrest 21 patients return of spontaneous circulation was achieved that is nearly 22.3%.
Mean age of patients with cardiac arrest was Mean ±SD: 57.02±16.76. Out of 150 patients, 90 were males and 60 were females and hence it is under-representative of the female population.
Out of 102 cardiac arrest cases on which defibrillation was attempted, for 80 patients defibrillation was attempted within 1-10secs, that is nearly 78.4%, which had an a significant impact on the outcome. Similar findings were put forth by Ian Jacobs et al7 who hypothesized that the outcome following cardiac arrest and cardiopulmonary resuscitation is dependent on critical interventions, particularly early defibrillation.
Out of 150 cases of cardiac arrest, 65 patients had initial rhythm of ventricular fibrillation of which 56 patients were alive at the time of discharge and 9 patients could not be revived. Nearly 30 patients had an initial rhythm of asystole of which only 10 patients that is 10.8% were alive and 20 patients that is 35.1% could not be revived. Only 2 patients that are 2.2% having PEA as initial rhythms were alive at the time of discharge and 18 patients that is 31.6% could not be revived. Thus patients with ventricular fibrillation had a better outcome when compared to asystole and PEA. The survival at discharge was higher for patients with VF than asystole and PEA. This was comparable to the study by Peberdy MA et al8 (2000) stated the combined discharge rate for adults was 18% and 27% in children post cardiac arrest. It stated that the discharge rates for VF is triple than that for asystole or pulseless electrical activity.
Out of total 104 cases in which defibrillation were attempted 84 patients were alive at discharge that is nearly 90.3% and 20 patients were not revived which is 35.1%. In a study, Fredriksson et al9 (2006) studied the primary endpoint for this study was survival to discharge. Thirty-seven percent survived to hospital discharge. The organization at SU is efficient; 80% of the cardiac arrest had CPR within 1 min. Time from cardiac arrest to first defibrillation is a median of 2 min. Almost two-thirds of the patients were admitted for cardiac related diagnoses. They concluded that current study is the largest single-centre study of in hospital cardiac arrest reported according to the Utstein guidelines. They reported a high survival for in-hospital cardiac arrest. They have pointed out that a functional chain of survival; short intervals before the start of CPR and defibrillation are probably contributing factors for this.
Survival status at discharge was significant in patients in whom chest compressions was started within 1-5seconds. Patients in whom defibrillation was attempted at the earliest had better survival. Hence proves the importance of early intervention, effective chest compression and rapid defibrillation. Dr Andy Lockey et al10 (June 2010) was to provide detailed variability in selection of patients who undergo attempted resuscitation and to describe the effectiveness of interventions. The study also focused on professional and public perception of survival following resuscitation.
Out of 150 patients, 94 patients achieved return of spontaneous circulation out of which 93 patients were alive up to discharge that is 127.4% and 1 patient did not survive up to discharge that is 5.3%. This was comparable to findings put forth by JL Chua et al (2015) which stated some predictors of return of spontaneous circulation and survival in in-hospital cardiac arrest.
Out of 65 patients with VF, 56 patients achieved return of spontaneous circulation that is 59.6%. Out of total 30 patients with asystole, 10 patients achieved return of spontaneous circulation that is 10.6% and 20 patients did not achieve return of spontaneous circulation that is 35.7%. Hence ventricular fibrillation has a better outcome when compared to asystole in cardiac arrest. This was similar to the results put forth by Ida Wibrandt et al11 (2015). The overall mortality was 44% and a favorable neurological outcome was seen among 52%. Strong predictors for survival and favorable neurological outcome were ventricular tachycardia/ventricular fibrillation (VT/VF) as initial rhythm, cardiac etiology and time to ROSC < 20 minutes. Age < 60 years was a predictor for survival only. Patients with the combination of VT/VF and ROSC < 20 minutes had undeniably the best chance of both survival and a favorable neurological outcome. They found significant predictors for both survival and neurological outcome, in which an initial rhythm of VT/VF and a cardiac etiology were the strongest. In a study by Patrick a et al12 (1998), the in-hospital Utstein Style was generally easy to follow, but there were several areas where adjustments may be of benefit. The study shows that there were 140 true arrest calls during this period, with 133 attempted resuscitations. Forty-seven patients had ROSC greater than 24 h, 35 were discharged alive and 30 were alive at 1 year. Of these 30 survivors, 27 had a Cerebral Performance Category of 1.
We have completed a 6 months follow up study of in hospital cardiopulmonary resuscitation using Utstein template, done as per ACLS guidelines, in Indian patients with cardiac arrest in the real world setting.
This study reveals a significant number of patients with cardiac arrest were in the age of 61-70 years, highlighting the increasing prevalence of cardiac arrest in the Indian population in elderly age group. The risk factors that were most commonly associated were hypertension, diabetes, ischemic heart disease and chronic kidney disease. The most common cardiac arrest rhythm with better outcome was ventricular fibrillation. Asystole and PEA had a poor outcome inspite of early and effective chest compressions. Patients with early defibrillation had a higher survival rate at discharge with a CPC-3 followed by CPC-2, hence proving the importance of rapid defibrillation being a critical intervention during resuscitation. Patients achieving ROSC had a better survival to discharge, which gradually declined after 6months of follow up. Patient with shockable rhythm, early chest compression and rapid defibrillation had higher incidence of achieving ROSC.