SCCM Resource Library-11-Severe Escalation of Out-of-Hospital Cardiac Arrests in SARS-CoV-2-Immersed Metropolitan Cities

Video Transcription

Hello, I'm Dr. Paul Pepe, and I'm here to report on our study on severe escalation of out-of-hospital cardiac arrest in SARS-CoV-2 immersed in metropolitan cities.  This is abstract 11 on page 6 of your supplement, if you want to look at it in more detail. The authors here are an incredible group, and they include people like Mike Osterholm,  who's a well-known epidemiologist, and on the Biden COVID advisory team right now, Remlin-Crowe, national research scientist, and the medical directors here of the 911 systems  for New York, Los Angeles, and their counterparts in Europe, such as Roberto Fomagali in Milano. But they represent a writing, they're a writing group on behalf  of the Metropolitan EMS Medical Directors Global Alliance. These are the doctors who are responsible for the paramedics training, their protocols and management,  and the quality assurance, and that becomes pertinent here because they were following cardiac arrest cases. Cardiac arrest for the out-of-hospital environment,  you already know it's difficult in the in-hospital environment, but it's not only a volatile, stressful, and complex kind of a situation you have to manage,  but it also takes away from other cases, even though they only constitute 1% of the 911 system calls, for example, on a day-to-day basis, they also consume probably 15 to 18%  of the resources and time because the time on scene, because of all the vehicles that will have to respond there, and also the time they take  to do all the actions you have to do, et cetera. So it really demands a lot. So any increases in cardiac arrest have a major impact that become logarithmic, quite frankly,  under the circumstances. So this group talks to each other regularly by email, but also in the early part of 2020, as COVID was coming along, they started twice-weekly Zoom calls  and got to talk about what was going on in their individual cities. And it was only as March, we began to say that there were as easy as increases in cardiac arrest.  This is long before lockdowns and so on. And after the lockdowns, they did notice major decreases in emergency department traffic, 911 system calls,  particularly with respect to trauma,  but they were beginning to observe these profound escalations in cardiac arrest cases, even before the lockdowns. And that becomes important here, by the way.  So the purpose of this study was to quantify any increases in cardiac arrest among the most populous US cities and others worldwide,  and also identify if there was any potential relationship to not only just to COVID-19, but to the infiltration of COVID-19, the local prevalence concurrently  at the time of these increases. So in terms of the methods, these 50 cities probably are responsible for,  the agencies are responsible for about a quarter of the US population that they probably encounter more though, probably close to that because of commuters, tourists, and so on.  Even people traveling in and out, the net group may be close to a third of the US population. So this is gonna be really representative of a lot of major parts of the country.  And then we also looked at counterpart metropolitan, European, Australia, New Zealand cities, and you'll see several, we'll report on some of these here in this talk.  So we normally look at our monthly cardiac arrest cases in most, some places we tabulate it daily, but just terms of reports,  we have monthly reports in most cities that are analyzed. And so we looked at the January, February, March, whatever through June for 2020,  and then compared it to the prior years, 2018 and 2019, we averaged those numbers to see if there was any increases from prior years.  So monthly variations do occur in cardiac arrest, but typically don't, not much more than 48%, even if you're accounting for say, 31 days in January or certain months  that are a little busier than others, or if February had a leap year last year. So any increases greater than 10% though, compared to 2018, 2019,  were operatory deemed to be highly significant. We have those numbers statistically, but also operationally, as I mentioned, do these case complexities and resource utilization risk  and not available for other calls. So the best available concurrent COVID-19 case estimates were being obtained through various sources that you are aware of,  specifically through the CDC and others that were tracking this. And we looked at it for each city and particularly with respect to low levels of attack  versus like less than 1,500 per 100,000 to high levels of attack, like greater than 3,000 per 100,000. So what were the findings? Well, as we all had presumed,  in January 2020, there wasn't much change from prior years, but then we started seeing some trends upward in certain cities during February,  but significantly we saw in certain cities, significant increases by March. And by April, absolute numbers of cardiac arrest cases across all 50 major cities,  whether they had increases or not,  were, I mean, I'm sorry, where they were impacted by COVID-19 or not, increased over 60% from about 7,000, 11,000. It's 4,300 case increase. And that becomes significant.  And because during April, 34 cities with relatively high COVID-19 attack rates had greater than 20%, not 10%, but 20% increase in cardiac arrest,  with 13 increasing over 50%, one and a half fold. Three epicenters that we're gonna report to you on London, New York, Detroit, had over double the usual number of cases,  two and a half fold, in fact, in New York during April. But what's gonna be important here is those numbers started returning to baseline in June when COVID-19 cases had diminished,  they'd gotten some control over it. And so it really did parallel things. And I'll show you some graphics to emphasize that. But conversely, despite the lockdowns, right,  cities with lower COVID-19 cases in April had no changes from prior years. That was in seven cases or even fewer cases in six. And some of that might be  because they weren't getting as many, fewer cases because they weren't getting as many people coming through, tourists or commuters or people staying home.  For example, Honolulu is one of those cities that remained pretty low in terms of cases because they were not getting that influx of tourists and so on.  But in June, many of these cities later had marked increases in cardiac arrests as things began to surge in their region. So we'll show you some examples such as Madison  and Charleston that when they had their surges, boom,  the cardiac arrest, if anything, not only parallel, but even preceded the increases in COVID-19 cases. So here's April. And just again, graphically, just to show you,  there's a 10% increase. And what happened was Madison didn't change much where Charleston was lower than usual. And that becomes a kind of an important thing  as we go along here later on, as I emphasized. So New York City, 250% and Detroit, you know, up over close to 150%. And those are just some examples  that I thought would stick out here. Because if you go into June, now Madison's way up, okay, almost 100% increase in same thing as trending here in Charleston,  whereas they were lower than before back in April. But this basically was predicted in a sense because they started getting higher in June and July.  And we'll show you that in just a second. Meanwhile, Detroit's going downwards as they're getting control there. And same thing in New York City  where they got really good control of the COVID-19 cases. And you can see here, they went down close to normal again. This graphic is important because as you can see,  here's March and New York City and Detroit were already showing increases in cases. And that is of note because we had only had reports of less than, I think, 2000 people,  1800 people dying from COVID in the United States as of April 1st were reported. When I just looked it up at the World Health Organization website.  And yet 500 cases more of cardiac arrest occurred in New York City during March.  And those cases, most of those died and they just were not resuscitatable. And importantly, they were not tested for COVID-19. So as a result, there probably were a lot more cases  that were due to COVID-19 that weren't getting reported in our statistics.  Let's move on here. Again, what I'm trying to get at here is that the key thing is that it really did track. So what you're looking at here on the left, for example,  of New York City in this graphic is the horizontal line in blue is showing how much that the cases of cardiac arrest had increased. And there it is over 50% in March.  And by April, it's going up to 250% and then down again, as I said, as they got it under control. And here are the day-to-day graphics and the vertical lines in black.  You can see as the cases track along and most importantly, in places like New York and Detroit, you can see that the cases were actually going up significantly  before they got impacted hard by COVID in terms of tests. That's probably because you're testing. After someone gets sick, they may not come in and get tested  for about a week or so. And then they may not get the results back later and then they're not reported later. So this may be actually a signal  because you're having the cardiac arrest maybe as your first symptom or as a complication of one of your first symptoms. And so as a result, it's gonna lag behind.  Cardiac arrest could be one, a signal that you're about to surge and also it could be used for identifying clusters in different areas.  And again, in Charleston and Madison, as you see here, they surged in late June into July and these cases were almost predictive signaling that they were getting,  whereas back in April, nothing was happening so they weren't seeing many cases.  We have some prediction of this in terms of our friends in Italy and we're starting to show that in the regions of the Lombardia, in the Milan area, where it had not attack rate,  they were seeing the same thing fewer, there wasn't any major increases, whereas in the cases in the areas, the regions, in Lombardia that got hit hard,  cardiac arrest cases went up as well. So this was not new, we're just really confirming what we saw in one region already. New York City also told us  that most of these people were not going to survive and so as a result, and they were not being tested.  So as a result, we have some inferences here that we weren't reporting a lot of COVID-19 related deaths. So why were they dying from this?  The theory is that when some people were putting out was that this was acute corny syndrome, people that were remaining at home afraid to be exposed to COVID-19,  but these cases were happening well before we even were putting out warnings to stay home, let alone lockdowns. And more importantly, when you're in the cities,  like we showed here, Charleston or Madison or Honolulu, whatever, those cases basically were, if anything, lower than usual. And most importantly is that it was areas  where the attack rate from COVID was not hard, but as soon as they got hit, it went up. So what is it? COVID-19 is probably a direct effect,  but is it causing hyperclotting and pulmonary emboli? Or is it a direct effect such as what we're thinking is a direct complication of the hyperclotting that we see?  And we early on did start noticing the hypercoagulopathy, but we also took it a step further, which is we were able to identify for a paper  that just a little shameless promotion here, we just published this in Critical Care Explorations. And thank you, by the way, to the editors there, they were very helpful.  And we show that integral use of thromboelastography tag, but with platelet mapping is the key thing, it became important, we really see that there was,  and by the way, this is gonna be reported here on abstract 176 on page 73. And we really wanted to emphasize that we probably were seeing some things in the endothelium,  there was an endotheliopathy, hyperclotting, et cetera, probably a lot of platelet aggregation that was going on. So the limitations here though, were that the COVID cases numbers  were not being entirely accurate and many asymptomatic people stayed home, there was lack of testing early on, delayed results, but it's still a reasonable reflection  of well-publicized attack rates and when these communities surged or dissipated, in terms of their COVID prevalence. I can't confirm cardiac arrest is a direct complication  of COVID-19, they were not tested for COVID-19, and it could be a secondary complication of pulmonary thromboemboli or MI, however, data still indicates a direct impact.  And I think it's likely causal and most likely an endotheliopathy, microthrombosis model, et cetera, with all the other nastiness that occurs that we see in other organs.  So the conclusions in major cities worldwide, there was a profound escalation of 911 system cardiac arrest that paralleled or even preceded concurrent local numbers of COVID-19.  And out-of-hospital cardiac arrest is most likely a clinical complication of COVID-19 and not just reticence to seek medical help in acute Corning syndrome cases.  And as COVID-associated patients are less likely to survive in terms of these COVID-associated cardiac arrests, and usually not tested,  and they were not counted as COVID-related deaths. And so the SARS-CoV-2 death toll is probably much higher than being reported. So with that, thank you very much, everyone.  Thank you for what you do on a day-to-day basis. Care about you guys all so much. So thanks a lot.

Video Summary

A study conducted on out-of-hospital cardiac arrest cases in metropolitan cities during the COVID-19 pandemic found a significant increase in these cases before and during the lockdown period. The study analyzed data from 50 major cities in the US and internationally. Results showed that in April, there was a 60% increase in cardiac arrest cases across all cities, with some cities experiencing a 250% increase. The study suggests that COVID-19 may be a direct complication leading to cardiac arrest, possibly due to hypercoagulopathy and clotting. It also implies that the number of COVID-related deaths may be higher than reported.

Asset Subtitle

Resuscitation, Crisis Management, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Paul E. Pepe, MD, MPH, MACP

Introduction/Hypothesis: Following COVID-19 stay-at-home directives in March 2020, many EMS systems worldwide observed 30-40% decreases in total call volumes. Simultaneously, most metropolitan cities severely impacted by COVID-19 also reported marked increases in out-of-hospital cardiac arrest (OHCA) cases. The study aim was to quantify the change in OHCA numbers observed in large urban centers during the onset of the COVID-19 crisis.

Methods: Major city EMS systems covering ~one-quarter of the U.S. population (n=45), and millions of others in major European/Australian cities, were surveyed for their monthly EMS OHCA numbers during the first 6 months of 2020. Data were compared to averaged corresponding monthly periods in 2018 and 2019. Considering normal variation and the complexities of OHCA cases (risk, significant personnel/resource utilization and protracted time away from other 9-1-1 responses), >10% increase/decrease was considered, a priori, a highly-significant difference, especially in terms of operational impact.

Results: Of the 45 major U.S. cities studied, large escalations in OHCA were associated with the relative prevalence of COVID-19. During April, 32 cities with high rates of COVID-19 had >15% increases in OHCA vs. prior years. Among 13 cities with >50% (1.5-fold) increases, 3 widely-recognized COVID-19 epicenters had >double their usual OHCA numbers (2.5-fold in NYC). Conversely, despite lockdowns, cities with relatively lower COVID-19 cases, had no change from prior years (n=6) or even fewer cases (n=6). Inclusive of all 45 cities, the mean number of OHCA cases/city rose in April by 62%, from 149 to 241 (p=0.037). By June, cities with the highest rates of OHCA, like NYC, returned to or approached pre-COVID levels after mitigating spread, while initial low impact cities with lower OHCA rates in April (eg, Phoenix, Charleston) experienced marked increases in June as local COVID-19 cases rose substantially. European/Australian cities mirrored the U.S. experience.

Conclusions: Metropolitan cities have experienced marked increases in OHCA during 2020 paralleling the prevalence of COVID-19 in their respective jurisdictions placing significant operational strains on affected 9-1-1 systems. These on-going observations are now part of a work in progress to elucidate the underlying etiologies.

Meta Tag

Content Type Presentation

Knowledge Area Resuscitation

Knowledge Area Crisis Management

Knowledge Level Intermediate

Knowledge Level Advanced

Learning Pathway Emergency Medicine and EMS Care

Membership Level Select

Tag COVID-19

Tag Cardiac Arrest

Year 2021

Keywords

out-of-hospital cardiac arrest

COVID-19 pandemic

lockdown period

metropolitan cities

hypercoagulopathy and clotting

Emergency Medicine and EMS Care

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