Nineteen years’ experience of out-of-hospital cardiac arrest in Gothenburg—reported in Utstein...

Nineteen years’ experience of out-of-hospital cardiac arrest inGothenburg*/reported in Utstein style

Martin Fredriksson *, Johan Herlitz, J. Engdahl

Division of Cardiology, Sahlgrenska University Hospital, SE-413 45 Goteborg, Sweden

Received 9 February 2003; received in revised form 27 February 2003; accepted 11 March 2003

Resuscitation 58 (2003) 37�/47

www.elsevier.com/locate/resuscitation

Abstract

Objective: To describe the outcome in the Utstein style for out of hospital cardiac arrest in Gothenburg, over a period of 19 years.

Methods: All consecutive cases of cardiac arrest between 1980 and 1999 in which the emergency medical service (EMS) system

responded and attempted resuscitation were reported and followed up for 1 year. Results: In all, there were 5270 attempts. 3871

(73%) of which were regarded as being of a cardiac aetiology. In these cases, information on witnessed status was missing in 782

cases (20%). Of the remaining 3089 cases, 2066 (67%) were bystander witnessed, 791 (26%) were unwitnessed and 232 (8%) crew

witnessed. The median interval between a call for the ambulance and the arrival of the first ambulance was 5 min. Thirteen percent

of the bystander-witnessed cases were discharged from hospital. Of the unwitnessed cases, only 2% were discharged from hospital,

whereas 22% of the crew-witnessed cases were discharged. Of the patients with a bystander-witnessed cardiac arrest of a cardiac

aetiology found in ventricular fibrillation (VF), 20% were discharged from hospital. Conclusion: In this large Utstein style study of

out of hospital cardiac arrest stretching over almost 19 years, we report high survival rates both for patients suffering a bystander-

witnessed cardiac arrest, and for the subgroup suffering a bystander-witnessed cardiac arrest with VF as the first recorded rhythm.

These high survival rates can in part be explained by the short time intervals from calls being received by the emergency dispatch

centre (EDC) to the arrival of the emergency medical service at the scene.

# 2003 Elsevier Ireland Ltd. All rights reserved.

Keywords: Out of hospital cardiac arrest; Outcome; Utstein

Resumo

Objectivo: Descrever, durante um perıodo de 19 anos, o prognostico, em estilo Utstein, da paragem cardıaca em Gotemburgo.

Metodos: Foram referidos e seguidos durante um ano todos os casos consecutivos de paragem cardıaca, entre 1980 e 1999, aos quais

o sistema dos servicos de emergencia medica (SEM) deu resposta e em que foram realizadas manobras de reanimacao. Resultados:

Registou-se um total de 5270 tentativas de reanimacao, destas 3871 (73%) foram interpretadas como tendo etiologia cardıaca. Em

782 (20%) destes casos faltava informacao sobre a altura da paragem. Nos restantes 3089 casos, 2066 (67%) foram testemunhados,

791 (26%) nao foram testemunhados e 232 (8%) testemunhados pela tripulacao. O intervalo medio entre a chamada da ambulancia e

a chegada desta foi de 5 minutos. Trinta por cento dos casos de paragem testemunhada tiveram alta do hospital. Apenas 2% dos

casos de paragem nao testemunhada tiveram alta do hospital, enquanto que este valor foi de 22% nos casos de paragem

testemunhada pela tripulacao. Nas vıtimas de paragem cardıaca, de etiologia cardıaca encontrados em Fibrilhacao Ventricular

(VF), testemunhada por quem se encontrava perto, verificou-se que 20% teve alta hospitalar. Conclusao: Neste estudo da paragem

cardıaca fora do hospital, relativo a 19 anos, estilo Utstein, referimos a ocorrencia de taxas de sobrevivencia mais elevadas para as

vıtimas de paragem cardıaca testemunhada e para o subgrupo das vıtimas de paragem cardıaca testemunhada que tinham como

primeiro ritmo registado a VF. Estas taxas de sobrevivencia mais elevadas podem ser explicadas em parte pelo pequeno intervalo de

tempo que medeia entre a chegada do pedido de ajuda ao centro- (Emergency Dispatch Centre -EDC) e a chegada dos servicos de

emergencia medica ao local.


* Corresponding author. Tel.: �/46-31-82-7973.

E-mail address: [email protected] (M. Fredriksson).

0300-9572/03/$ - see front matter # 2003 Elsevier Ireland Ltd. All rights reserved.

doi:10.1016/S0300-9572(03)00115-1

mailto:[email protected]

Palavras chave: Paragem cardıaca fora do Hospital; Prognostico; Utstein

Resumen

Objetivo : Describir el resultado en el paro cardıaco en Gothenburg en el estilo Utstein, durante un perıodo de 19 anos. Metodos :

Se reportaron y siguieron por un ano todos los casos consecutivos de paro cardıaco entre 1980 y 1999 en los que se alerto el sistema

de servicio de emergencias medicas (EMS) y se intento resucitacion. Resultados : Hubieron en total 5270 intentos. 3871 (73%) de los

cuales fueron considerados de etiologıa cardıaca. En estos casos, faltaba la informacion acerca si el paro fue presenciado en 782

casos (20%). De los 3089 casos restantes, 2066 (67%) fueron presenciados por personas cercanas, 791 (26%) no fueron presenciados y

232 (8%) presenciados por personal en servicio. La mediana del intervalo entre la llamada de la ambulancia y la llegada de la

primera ambulancia fue de 5 minutos. 13% de los casos presenciados por testigos locales fueron dados de alta vivos del hospital. De

los casos no presenciados, solo el 2% fueron dados de alta vivos del hospital, mientras que el 22% de los presenciados por personal

de ambulancia fueron dados de alta vivos. De los pacientes con paro de etiologıa cardıaca, presenciado por testigos locales,,

encontrados en fibrilacion ventricular (VF), 20% fueron dados de alta vivos del hospital. Conclusion : En este amplio estudio en estilo

Utstein de paro cardıaco extrahospitalario que incluye cerca de 19 anos, reportamos altas tasas de sobrevida tanto para pacientes de

paro presenciado por testigos locales, como para el subgrupo de paro presenciado por testigos locales con VF como primer ritmo

registrado. Estas altas tasas de sobrevida pueden ser explicadas en parte por los intervalos cortos de llamadas que son recibidas por

el centro de despacho de emergencias (EDC) hasta la llegada del servicio de emergencias medicas a la escena.


M. Fredriksson et al. / Resuscitation 58 (2003) 37�/4738

Palabras clave: Paro cardıaco extrahospitalario; Resultado; Utstein

1. Introduction

The Utstein guidelines for reporting out of hospital

cardiac arrest were created for more than 10 years ago,

in the Utstein Abbey on the Norwegian coast. These

guidelines have been of great importance, since they

created a uniform nomenclature, and way of reporting.The guidelines have been followed by Utstein guidelines

for trauma care and, paediatrics.

We report outcome in the ‘Utstein style’ for out-of-

hospital cardiac arrest in Gothenburg, Sweden’s second

largest city. It has been shown previously that a short

time interval from collapse to first defibrillation, by-

stander witnessed arrests and bystander cardiopulmon-

ary resuscitation (CPR) have a positive effect onsurvival [1�/8]. In spite of this, there is large-scale

variability in the rates of patients with a witnessed

cardiac arrest of cardiac aetiology being discharged

from hospital reported in the ‘Utstein style’. Previously

published results for patients suffering a bystander-

witnessed arrest range from 2.1%, reported in New York

[1], to 49%, reported in the San Juan Islands [7]. The

area needs to be further studied.

2. Methods, settings and definitions

Between 1 October 1980 and 31 August 1999, all

consecutive cases of cardiac arrest in which the emer-

gency medical service (EMS) system responded andattempted resuscitation were reported and followed up

for 1 year. From the EMS logbook, we collected the

background data on the patients who had undergone a

resuscitation attempt. We then collected the data for

each case from the ambulance trip sheet, the hospital

records and death certificates. The data was written into

a database following a formal protocol to ensure high

quality.

We have compared our results with those in other

published Utstein style reports. Like ours, these studieshave also reported not only the results of bystander-

witnessed cardiac arrest but also the results of unwit-

nessed cardiac arrests and EMS-witnessed cardiac

arrests, as preferred in the Utstein guidelines [9].

2.1. Study area and population

Gothenburg is a city with an area of 455 km2. In 1980,

the resident population was 431 273, of which 48.6%

were men and 16.2% were aged 65 and over. In 1999, the

resident population was 462 470, of which 48.9% were

men and 15.6% were aged 65 and over. The age

distribution of the population in 1999 is shown in Fig.

1. In 1996, the total number of deaths was 5065, 24% of

which were due to ischaemic heart disease. In the sameyear, 1116/100 000 a year died in Gothenburg. In the

55�/64 age group, 71 men (rate 351/100 000 a year) and

17 women (rate 84/100 000 a year) died of ischaemic

heart disease in 1996. The absolute number of cardiac

arrests did not change significantly over time. In 1981

there were 239 cardiac arrests and in 1997 there were

234. The highest number was seen in 1986 (314) and the

lowest in 1982 (226).Three thousand six hundred and forty-two persons

completed a CPR course in Gothenburg in 2000. The

corresponding figure for the last 5 years is 18 873. In

Gothenburg in 1999, 81.2% of the population had an

educational level past compulsory school.

2.2. The emergency medical service (EMS)

In Sweden, a person in distress dials 112 to get in

touch with the fire department, medical service or

police. At the beginning of the study, the number was90 000, but in 1996 the number was changed to comply

with the uniform emergency telephone number through-

out the European Union (112). The old number is still in

operation in parallel with the new one. In Gothenburg,

there is a community wide two-tier ambulance system.

2.2.1. The emergency dispatch centre (EDC) in

Gothenburg

In an average year, the EDC handles about 730 000

calls, 50�/70% of which are real emergency calls, while

the rest are hoax calls. In 2000, the EMS had 41 591

medical dispatches. In 5377 of these cases, the secondtier was dispatched.

The dispatcher receiving the call questions the caller

using a formal protocol to find out what kind of help

they need (fire, medical, police). While questioning the

caller, the dispatcher uses a computerised system to get a

colleague to dispatch an ambulance. If the call is about

severe chest pain, collapse for an unknown reason, or

suspected cardiac arrest, a second ambulance withadvanced life support (ALS) equipment will also be

dispatched. The dispatchers are trained in giving tele-

phone-assisted cardio-pulmonary resuscitation (CPR).

2.2.2. The ambulances

In Gothenburg, there are 12 ambulances which are

available around the clock, plus 5 daytime ambulances,

which can also be staffed around the clock in extreme

situations. In addition, there are two ALS-equipped

ambulances, known as ‘‘OLA’’ ambulances. The ambu-

lances are situated at local fire stations around the city.

An ambulance uses a general resuscitation protocol

recommended by the Swedish Society for Cardiology,

the Swedish Society for Anaesthesiology and Intensive

Care Medicine and the Scandinavian Resuscitation

Council. The ambulance crews have standing orders to

initiate therapy in cardiac arrest. The criteria for ceasing

resuscitation ‘in the field’ are asystole for more than 30

min.

. First tier: an ambulance with two emergency medical

technicians (EMT) on board, who are trained to give

basic life support (BLS). They are also trained to use

an automated external defibrillator (AED). This

equipment was gradually introduced in the period

between 1987 and 1991.

. Second tier: an ALS-equipped ambulance with the

capacity to carry patients. Between 1980 and 1984, it

was crewed by two paramedics and, in 1985�/1997, it

was also staffed by one nurse (the nurse was not on a

regular schedule). Since 1997, there has been one

paramedic and one nurse for 24 h/7 days a week.

Most of the nurses are trained in anaesthesiology, but

a few of them are still coronary care unit (CCU)

nurses, although the goal is that all nurses should be

trained in anaesthesiology.

Fig. 1. Age distribution.

M. Fredriksson et al. / Resuscitation 58 (2003) 37�/47 39

2.3. Statistical methods

A two-tailed Pitman’s non-parametric permutation

test was used. A P -value of B/0.05 was regarded assignificant.

2.4. Cerebral performance category (CPC)

CPC 1�/2 represents good neurological outcome, with

none or mild impairment, capable of the activities of

daily living (ADL). CPC 3�/4 represent poor neurologi-

cal outcome, dependent on others for ADL or, living in

a sheltered environment.

3. Results

3.1. Utstein template general results

The population in Gothenburg in 1999 was 462 470.

Resuscitation was attempted 5270 times during thestudy period (Plate 1). Of these cases, 3871 were of

cardiac aetiology and 1330 were of non-cardiac aetiol-

ogy. This information was not available in 69 cases.

Information about whether the arrest was witnessed or

not was missing in 782 of the 3871 cases. The cardiac

arrests were bystander witnessed in 2066 cases (66.9%),

witnessed by EMS personnel in 232 cases (7.5%) and not

witnessed in 791 cases (25.6%).

3.2. Unwitnessed cardiac arrests of cardiac aetiology

Asystole was the most common initial rhythm,

reported in 54% of cases (Plate 2). Ventricular fibrilla-

tion (VF) was reported in 28% of the patients and

ventricular tachycardia (VT) was reported in less than

1%. Other rhythms accounted for 17% of the cases. In

three of the 791 cases, information about initial rhythm

could not be ascertained. Twelve percent of the patients

received CPR from a bystander. Patients with VF as the

first registered rhythm received bystander CPR more

than twice as often compared with other rhythms.

Thirteen percent of the 791 cases were admitted to

hospital. Sixteen percent of the patients who wereadmitted to hospital were discharged alive and 71% of

them were still alive after 1 year. Overall survival to

discharge from hospital for this group was 2.1%. The

patients were discharged to their homes in 24% of the

cases, while 29% were discharged to rehabilitation

facilities, 41% were discharged to nursing homes and

6% were discharged to other destinations.

3.3. Bystander-witnessed cardiac arrests of cardiac

aetiology

VF was the most common initial rhythm, reported in

60% of the cases, while VT was reported in less than 1%

(Plate 3). Asystole was reported in 20% of the patients.

Other rhythms accounted for 19% of the cases. In eight

of the 2066 cases, information about the initial rhythm

could not be ascertained. Twenty-seven percent of thepatients received CPR from a bystander, patients found

in VT/VF received bystander CPR most frequently.

Thirty-two percent of the 2066 cases were admitted to

hospital. Forty-one percent of the patients who were

admitted to hospital were discharged alive and 78% of

them were still alive after 1 year. Overall survival to

discharge from hospital for this group was 13%. The

patients in this subset were discharged to their homes in53% of the cases, while 32% were discharged to

rehabilitation facilities, 12% were discharged to nursing

homes and 2% were discharged to other destinations.

3.4. EMS personnel-witnessed cardiac arrests of cardiac

aetiology

VF was the most common initial rhythm, reported in40% of the cases. VT was reported in 5% (Plate 4).

Asystole was reported in 19% of the patients. Other

rhythms accounted for 35% of the cases. In two of the

232 cases, information about the initial rhythm could

not be ascertained. Forty percent of the 232 cases were

admitted to hospital. Fifty-seven percent of the patients

who were admitted to hospital were discharged alive and

77% of them were still alive after 1 year. Overall survivalto discharge from hospital for this group was 22.4%.

The patients were discharged to their homes in 83% of

the cases, while 15% were discharged to rehabilitation

facilities and 2% were discharged to nursing homes.

3.5. The Utstein ‘golden standard’

The Utstein guidelines recommend that the numberdischarged alive divided by the number of persons with

bystander-witnessed cardiac arrest in VF of cardiac

aetiology is to be used for intersystem comparisonsPlate 1. General results.


(Table 1). We report that almost 20% survived in this

subset.

3.6. Time intervals (all time intervals given as median

values)

The time interval from the cardiac arrest to a call

being received by the EDC was 1 min. The first

ambulance arrived 5 min after the cardiac arrest. The

ALS unit arrived 8 min after the cardiac arrest. The time

from the cardiac arrest until the first defibrillation was 8

min.

3.7. Cerebral performance category (CPC) score at

discharge

Of the patients suffering a bystander-witnessed car-

diac arrest, 47% had a CPC score of one, while 70.5%

had a CPC score of two or better at discharge. The

corresponding figures for cardiac arrests witnessed by

EMS personnel were 86.5% for a CPC score of one and

Plate 2. Cardiac arrest not witnessed.

Plate 3. Bystander witnessed cardiac arrest.


92.2% for a CPC score of two or better. Patients with an

unwitnessed cardiac arrest had a CPC score of one in

29.4% of the cases, while 35.3% had a CPC score of two

or better.

3.8. Survival over time

The overall survival rate for patients suffering a

witnessed cardiac arrest of cardiac aetiology found in

VF is increasing (P B/0.0005) (Fig. 2). However, it is

somewhat of a rollercoaster; an initial period of decline

followed by a steep increase in survival 1991 and a

subsequent decrease towards the end of the study

period.

3.9. Survival over time among patients admitted to

hospital

No statistical significance was seen (Fig. 3).

4. Discussion

4.1. Utstein template general results

We are unable to provide information about the

confirmed cardiac arrests in which no resuscitation was

attempted (Plate 1). It has been demonstrated by

Weston et al. that, for every three attempts that are

made, there are two in which no attempt is made [10].Sixty-seven percent of the cardiac arrests were bystander

witnessed; other studies report a wide spread in the

percentage of witnessing, ranging from 38% [1] to 89%

[2]. Factors that affect this include the location of where

the cardiac arrest took place and demographics.

4.2. Unwitnessed cardiac arrests of cardiac aetiology

Our results show a higher rate of asystole than VF,

which is comparable with other previously published

results [8] (Plate 2 and Table 1). The 2.1% overall

survival to discharge in this sub-group was better than

that reported in Ljubljana [2], South Glamorgan [5] and

Amsterdam [4]. This could be explained in part by the

markedly longer time intervals from a call being received

to the EMS arriving at the scene in all three [2,4,5] andtime is essential for survival [8]. Both St-Etienne [6] and

Bonn [8] report better survival to discharge for this

subset. However, in St-Etienne [6], the 5% survival

represents only one person, due to the small total

number included in the study and this figure must

therefore be interpreted with caution. The Bonn study

[8] reports on patients who were all treated by physician-

staffed ALS ambulances, which might be regarded as anadvantage compared with paramedic- and EMT-staffed

BLS-D ambulances [11]. As can be seen in Table 1, both

South Glamorgan [5] and Amsterdam [4] report higher

overall CPR rates in this subset than our study, while

the others report lower values [2,6,8]. No apparent

association between survival and bystander CPR can

be seen in this subset in Table 1.

4.3. Bystander-witnessed cardiac arrests of cardiac

aetiology

The overall CPR rate is similar to that in Bonn [8], but

it is low in comparison to others [4�/6] (Plate 3, Table 1,

Plate 4. EMS-personnel witnessed arrest.


Figs. 2 and 3). CPR rates for patients found in VF are

quite low compared with others [4�/6,8]. If Gothenburg

is compared with South Glamorgan [5], both of which

have populations which are more or less equal in size, asignificantly smaller number of persons completed a

CPR course in Gothenburg than in South Glamorgan

[5]; 18 800 compared with 22 600 for the past 5 years

from the completion of each study. The lower number in

Gothenburg could be part of the explanation of the

lower bystander CPR rates in out-of-hospital cardiac

arrest reported in this study.

Overall survival for this subset was 13%, significantlyhigher than reports from Ljubljana [2], South Glamor-

gan [5] and St-Etienne [6] but considerably lower than

the rate reported from Bonn [8]. One major factor in

explaining the lower reported survival rates is probably

the markedly longer time intervals from a call being

received to the arrival of the EMS at the scene in these

studies [2,5,6] and time is essential for survival [8].

Bonn’s [8] high survival rate could be partly dependenton the fact that all the patients included in the study

were treated by physician-staffed ALS ambulances,

which might be regarded as an advantage and makes

the result harder to compare with the results of studies

with paramedic- and EMT-staffed BLS-D and ALS

ambulances[11].

In our study, the overall trend for survival in this

subset is increasing as time passes. However, there aretwo different formations in the chart in Fig. 2 that are

extra interesting. First we have the most obvious, a steep

increase in survival in 1991. This is most probably due to

completion of AED-availability in the first-tier ambu-

lances. The factors behind the decline in survival of the

periods 1981�/1990 and 1991�/1998 could be explained

by a change in patient characteristics. The mean decline-

rates for the two periods are very similar, suggesting thatthe same background factors operates in the two time

periods. It has previously been shown that the median

age for patients suffering out-of-hospital cardiac arrest

in Gothenburg has risen during the period, from age 68

in 1981 to age 73 in 1997 [12]. With this comes the

probability of a higher degree of co-morbidity, influen-

cing both the occurrence of VF and survival in a

negative way [13,14]. There is no statistical associationbetween survival among patients admitted to hospital

and time. The pattern in Fig. 3 is very similar to that in

Fig. 2. It seems reasonable to assume that the problems

associated with increased age and co-morbidity also

apply here.

4.4. EMS personnel-witnessed cardiac arrests of cardiac

aetiology

This subset has the best survival to discharge in our

study. This is the same sort of pattern as previously seen

in other studies [1,3�/7].Tab

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Fig. 2. Percent discharged alive over time for patients suffering a witnessed cardiac arrest found in VF.

M.

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Fig. 3. Percent discharged alive over time for patients admitted to hospital after suffering a bystander witnessed cardiac arrest found in VF.

M.

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4.5. The Utstein golden standard*/percentage of patients

in C.A. of cardiac aetiology found in VF who were

discharged alive from hospital

We report almost 20% survival to discharge in this

subset, which is comparable with the figure from

Amsterdam [4], even though Table 1 shows that there

is a clear discrepancy between our study and the one

from Amsterdam [4], indicating that both centres have

relatively good survival for partly different reasons. In

our case, the most important contributor to survival is

probably the short time interval from a call beingreceived by the EDC to the arrival of the EMS at the

scene. Amsterdam [4] has an important contributor in

the high level of bystander CPR. This spotlights the

importance of different links in the chain of survival.

Even if some links in the chain of survival have not been

optimised, this can be partly compensated for by other

links.

4.6. Time intervals

We report the shortest time interval from a call being

received by the EDC to the arrival of the EMS in

Gothenburg. It is our stated strategy to reach 97% of the

citizens within 10 min and we have therefore placed the

fire departments (which also house the ambulances) at

strategic locations.

It has previously been shown that witnesses of cardiacarrest often attempt to call a relative or doctor before

alerting the EMS [4,15]. In our study, the time interval

from the collapse until the call is received by the EMS is

comparable with other results [3,4]. However, we have

not investigated whether the first call after the collapse

was to the EDC or someone else.

4.7. CPC score

The data infers that the persons suffering an EMS-

witnessed cardiac arrest had the best neurological out-

come and the arrests which were not witnessed had the

poorest outcome. However, the post arrest neurological

condition must be interpreted with caution, because the

CPC values for the patients prior to the cardiac arrest

were not available.

4.8. Improving survival

In Gothenburg, we have a relatively low rate of

bystander CPR compared with other cities [5,6,8]. In

order to increase our survival rates, efforts must be

made to improve bystander CPR. A previous study has

shown that the percentage of patients in VF wasincreased at all time points by the provision of bystander

CPR [16]. It has also been shown previously that

patients found in VF have the best survival rates [1�/

8]. It is therefore important to educate more people in

CPR, as Gothenburg has experienced a troublesome

trend in recent years, with fewer persons taking part in

CPR courses, compared with an area with a populationof equal size [5]. However, this trend has to be seen in

perspective; almost 100 000 CPR courses have been

completed in the municipality of Gothenburg. So it

may not be the lack of knowledge that stops lay people

from giving CPR, but instead the fear of doing it

incorrectly and causing more damage than benefit

although this is pure speculation.

An additional way to improve survival is to shortenthe time interval from the collapse until the first shock is

administered. Our reported figure represents a median

time interval for a 20-year period, but it has previously

been shown that the time interval from collapse until

first shock is decreasing over time (9 min (median) in

1981 down to 6 min (median) in 1997) [12]. To shorten

this interval still further, there must be marked struc-

tural changes in organisation, including defibrillation byfire fighters and policemen. This needs to be further

investigated.

5. Conclusion

In this large Utstein style study of out-of-hospital

cardiac arrest stretching over almost 19 years, we report

a 13% survival rate for patients suffering a bystander-

witnessed cardiac arrest. For persons suffering a by-

stander-witnessed cardiac arrest with VF as the first

recorded rhythm, the survival rate was 19.7%. This is ahigh figure and can be explained in part by short time

intervals from a call being received by the EDC to the

arrival of the emergency medical service at the scene. In

this study, we have identified a troublesome trend*/

fewer lay persons have been trained in basic CPR in

Gothenburg compared with other areas [5] in recent

years. This is reflected in a low percentage of bystander

CPR compared with other studies [4�/6,8]. In order toimprove survival in Gothenburg, we must educate more

lay persons in basic CPR and show the general public

clearly the benefits in terms of survival from cardiac

arrest when a bystander gives CPR.

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Nineteen years’ experience of out-of-hospital cardiac arrest in Gothenburg—reported in Utstein...

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